mhGAP humanitarian intervention guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 5 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸ Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 5 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸ Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 25-50 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 25-50 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 25-50 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 25-50 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 25-50 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 25-50 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 25-50 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide (mhGAP-HIG) mental health Gap Action Programme WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1.Mental Disorders. 2.Substance-related Disorders. 3.Nervous System Diseases. 4.Relief Work. 5.Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 154892 2 (NLM classification: WM 30) © World Health Organization 2015 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Suggested citation: World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015. Contact for feedback and communication: Department of Mental Health and Substance Abuse at WHO (mhgap-info@who.int) or the Public Health Section at UNHCR (HQPHN@unhcr.org) iToday, the world is facing an unprecedented number of humanitarian emergencies arising from armed conflicts and natural disasters. The number of refugees and internally displaced persons has not been so high since the end of World War II. Tens of millions of people – especially in the Middle East, Africa and Asia – are in urgent need of assistance. This includes services that are capable of addressing the population’s heightened mental health needs. Adults and children affected by emergencies experience a substantial and diverse range of mental, substance use, and neurological problems. Grief and acute distress affect most people, and are considered to be natural, transient psychological responses to extreme adversity. However, for a minority of the population, extreme adversity triggers mental health problems such as depressive disorder, post-traumatic stress disorder, or prolonged grief disorder – all of which can severely undermine daily functioning. In addition, people with severe pre-existing conditions such as psychosis, intellectual disability, and epilepsy become even more vulnerable. This can be due to displacement, abandonment, and lack of access to health services. Finally, alcohol and drug use pose serious risks for health problems and gender-based violence. At the same time that the population’s mental health needs are significantly increased, local mental health-care resources are often lacking. Within such contexts, practical and easy-to-use tools are needed more than ever. This guide was developed with these challenges in mind. The mhGAP Humanitarian Intervention Guide is a simple, practical tool that aims to support general health facilities in areas affected by humanitarian emergencies in assessing and managing mental, neurological and substance use conditions. It is adapted from WHO’s mhGAP Intervention Guide (2010), a widely-used evidence- based manual for the management of these conditions in non-specialized health settings, and tailored for use in humanitarian emergencies. This guide is fully consistent with the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings and the UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations, which call for a multisectoral response to address the mental health and social consequences of humanitarian emergencies and displacement. It also helps realize a primary objective of the WHO Comprehensive Mental Health Action Plan 2013-2010, namely to provide comprehensive, integrated and responsive mental health and social care services in community-based settings. We call upon all humanitarian partners in the health sector to adopt and disseminate this important guide, to help reduce suffering and increase the ability of adults and children with mental health needs to cope in humanitarian emergency settings. Foreword Margaret Chan Director-General World Health Organization António Guterres United Nations High Commissioner for Refugees

iii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Advice for Clinic Managers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings (GPC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Principles of Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Principles of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Principles of Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Principles of Reducing Stress and Strengthening Social Support. . . . . . . . . . . . . . . 8 5. Principles of Protection of Human Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Principles of Attention to Overall Well-being . . . . . . . . . . . . . . . . . . . . . . . . 11 Modules Acute Stress (ACU)1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Grief (GRI)2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Moderate-severe Depressive Disorder (DEP)3. . . . . . . . . . . . . . . . . . . . . . . . . . 21 Post-traumatic Stress Disorder (PTSD)4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Psychosis (PSY)5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Epilepsy/Seizures (EPI)6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Intellectual Disability (ID)7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Harmful Use of Alcohol and Drugs (SUB)8. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suicide (SUI)9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Other Significant Mental Health Complaints (OTH)10. . . . . . . . . . . . . . . . . . . . . . 53 Annexes Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions . . . . . . . . . . 56 Annex 2: Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Annex 3: Symptom Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table of Contents iv Acknowledgements Conceptualization Mark van Ommeren (WHO), Yutaro Setoya (WHO), Peter Ventevogel (UNHCR) and Khalid Saeed (WHO), under the direction of Shekhar Saxena (WHO) and Marian Schilperoord (UNHCR) Project Writing and Editorial Team Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) and Mark van Ommeren (WHO) WHO mhGAP Review Team Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright and M. Taghi Yasamy Other Contributors/Reviewers Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (WHO Collaborating Centre for Research and Training in Mental Health, University of Verona), Thomas Barrett (University of Denver), Pierre Bastin (International Committee of the Red Cross), Myron Belfer (Harvard Medical School), Margriet Blaauw (IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings), Boris Budosan (Malteser International), Kenneth Carswell (WHO), Jorge Castilla (ECHO-European Commission), Vanessa Cavallera (WHO), Elizabeth Centeno-Tablante (WHO), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (University of Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontière, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (Ministry of Public Health Lebanon), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (University of Geneva), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australia), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (WHO), Mathijs Hoogstad (in non-affiliated capacity, the Netherlands), Peter Hughes (Royal College of Psychiatrists, United Kingdom), Takashi Izutsu (World Bank), Lynne Jones (Harvard School of Public Health), Devora Kestel (Pan American Health Association/WHO), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, the Netherlands), Marc Laporta (McGill University), Jaak Le Roy (in non-affiliated capacity, Belgium), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israel), Andreas Maercker (University of Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (WHO), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzania), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaysia), Emilio Ovuga (Gulu University, Uganda), Sarah Pais (WHO), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaysia), Pau Perez-Sales (Hospital La Paz, Spain), Giovanni Pintaldi (MSF), Bhava Poudyal (in non-affiliated capacity, Azerbaijan), Rasha Rahman (WHO), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (WHO), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japan), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University and Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (WHO), Inka Weissbecker (IMC), Nana Wiedemann (International Federation of Red Cross and Red Crescent Societies) and William Yule (King’s College London). Funding United Nations High Commissioner for Refugees (UNHCR) Design Elena Cherchi 1Introduction This guide is an adaptation of the WHO mhGAP Intervention Guide (mhGAP-IG) for Mental, Neurological and Substance Use Disorders in Non-specialized Health Settings for use in humanitarian emergencies. Accordingly, it is called the mhGAP Humanitarian Intervention Guide (mhGAP-HIG). These include general physicians, nurses, midwives and clinical officers, as well as physicians specialized in areas other than psychiatry or neurology. In addition to clinical guidance, the mhGAP programme provides a range of tools to support programme implementation useful for situational analysis, adaptations of clinical protocols to local contexts, programme planning, training, supervision and monitoring.1 What is mhGAP? Why is there a need for adaptation to humanitarian emergency contexts? Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity, as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Humanitarian crises pose a set of challenges as well as unique opportunities for providers of health services. Opportunities include increased political will and resources to address and improve mental health services.2 Challenges include: H » eightened urgency to prioritize and allocate scarce resources L » imited time to train health-care providers L » imited access to specialists (for training, supervision, mentoring, referrals or consultations) L » imited access to medications due to disruption of usual supply chain. The mhGAP Humanitarian Intervention Guide was developed in order to address these specific challenges of humanitarian emergency settings. 1 Email mhgap-info@who.int to obtain a copy of these tools. 2 See World Health Organization (WHO). Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. The mental health Gap Action Programme (mhGAP) is a WHO programme that seeks to address the lack of care for people suffering from mental, neurological and substance use (MNS) conditions. As part of this programme, the mhGAP Intervention Guide (mhGAP- IG) was issued in 2010. mhGAP-IG is a clinical guide on mental, neurological and substance use disorders for general health-care providers who work in non- specialized health-care settings, particularly in low- and middle-income countries. Contents of this guide Other changes include the following: G » uidance on conduct disorder was rewritten as guidance on behavioural problems in adolescents, found in the module on other significant mental health complaints (OTH). T » he module Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module (WHO, 2013) was separated into 3 modules: acute stress (ACU), grief (GRI) and post-traumatic stress disorder (PTSD). A » glossary has been added. Terms marked with the asterisk symbol * are defined in Annex 2. This guide is considerably shorter in length compared with the mhGAP-IG. It does not contain guidance on: A » lcohol and drug intoxication and dependence* (however, alcohol withdrawal and harmful alcohol and drug use are covered in this guide); A » ttention deficit hyperactivity disorder (however, adolescent behavioural problems are covered in this guide’s module on other significant mental health complaints); A » utism-spectrum disorders; D » ementia (however, support for carers of people with any MNS condition is covered in this guide’s General Principles of Care); N » on-imminent risk of self-harm; S » econd-line treatments for most MNS conditions. Guidance on these latter topics continues to be available in the full mhGAP-IG. The mhGAP Humanitarian Intervention Guide contains first-line management recommendations for MNS conditions for non-specialist health-care providers in humanitarian emergencies where access to specialists and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts. This guide covers: A » dvice for clinic managers; G » eneral principles of care applicable to humanitarian emergency settings, including: Provision of multi-sectoral support in accordance ◆ with the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007), Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations (UNHCR, 2013) and other emergency- related tools; Instructions on stress reduction; ◆ B » rief modules on the assessment and management of: Acute stress (ACU) ◆ Grief (GRI) ◆ Moderate-severe depressive disorder (DEP) ◆ Post-traumatic stress disorder (PTSD) ◆ Psychosis (PSY) ◆ Epilepsy/seizures (EPI) ◆ Intellectual disability (ID) ◆ Harmful use of alcohol and drugs (SUB) ◆ Suicide (SUI) ◆ Other significant mental health complaints (OTH). ◆

3The integration of mental, neurological and substance use (MNS) conditions in general health care needs to be overseen by a leader (e.g. district-level public health officer, agency medical director, etc.) who is responsible for designing and coordinating care in a number of health facilities, based on relevant situation analyses (see WHO & UNHCR [2012] assessment toolkit). Each facility has a clinic manager (head of the health facility) with specific responsibilities. Clinic managers need to consider the following points. Environment Consider having the room unmarked, in order to prevent » avoidance of MNS services out of fear of social stigma. Arrange for a » private space, preferably a separate room, to do consultations for MNS conditions. If a separate room is not available, try to divide the room using curtains or other means in order to optimize privacy. Service model Consider having at least one trained staff member be » physically present at any given time on “MNS duty”, i.e. a person who is assigned to assess and manage people with MNS conditions. Alternatively, consider holding a weekly or twice-weekly » “MNS clinic” within the general health facility, at a time of the day when the clinic is less busy. If people show up during non-MNS clinic times, they could gently be asked to come back when the clinic is being held. Setting up such MNS clinics can be helpful in busy health facilities, especially for conducting initial assessments that typically take longer than follow-up visits. Staffing and training Brief all staff about providing a » supportive atmosphere for people with MNS conditions. I » dentify staff members to be trained on MNS care. E » nsure that resources are available not only for the training but also for supervision. Clinical supervision of staff is an essential part of good MNS care. I » f only a few staff can be trained on the contents of this guide, then ensure that the rest of the clinical staff can offer psychological first aid (PFA)* at the least. Orientation on PFA can be provided in approximately half a day. The Psychological First Aid Guide for Field Workers and accompanying Orientation materials for facilitators can be found online. O » rient the receptionist (or person with similar role) on how to deal with agitated people who may demand or require immediate attention. Tr » ain community workers and volunteers, if available, on how to (a) raise awareness about MNS care (see below), (b) help people with MNS conditions to seek help at the clinic and (c) assist with follow-up care. C » onsider assigning someone in the health-care team (e.g. a nurse, a psychosocial worker, a community social worker) to be trained and supervised to provide psychosocial support (e.g. providing brief psychological treatments, running self-help groups, teaching stress management). O » rient all staff on local protection arrangements: Requirements for and limitations of consent, ◆ including reporting around suspected child abuse, sexual and gender-based violence and other human rights violations; Identifying, tracing and reuniting families. Separated ◆ children in particular must be protected and referred to appropriate temporary care arrangements, if needed. I » f international mental health professionals are attached to the clinic to provide supervision, they should be briefed about the local culture and context. O » rient all staff on how to refer to available services. Advice for Clinic Managers Referral Ensure that the clinic has an updated contact list for » referrals for the care of MNS conditions. Ensure that the clinic has an updated contact list for » other available sources of support in the region (e.g. basic needs such as shelter and food aid, social and community resources and services, protection and legal support). 4Raising awareness around available services Prepare messages for the community about available » MNS care (e.g. purpose and importance of MNS care, services available at the clinic, clinic location and hours). D » iscuss the messages with community leaders. U » tilise various information distribution channels, e.g. radio, posters at health clinics, community workers or other community resources who can inform the general population. W » here appropriate, consider discussing the messages with local indigenous and traditional healing practitioners who may be providing care for people with MNS conditions and who may be willing to collaborate and refer certain cases (for guidance, see Action Sheet 6.4 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC, 2007]). R » each out to marginalized groups who may not be aware of or have access to the clinic. Medicines W » ork with relevant decision-makers to ensure a constant supply of essential medicines. E » nsure availability of: at least one antipsychotic medicine (tablet and ◆ injectable forms) at least one anti-Parkinsonian medicine (to deal ◆ with potential extrapyramidal side effects*) (in tablet form) at least one anticonvulsant/antiepileptic medicine ◆ (tablet form) at least one antidepressant medicine (tablet form) ◆ and at least one anxiolytic medicine (tablet and injectable ◆ forms). Yo » u may have access to the Interagency Emergency Health Kit (IEHK) (WHO, 2011), a large box with medicines and medical supplies designed to meet the expected primary health-care needs of 10 000 people exposed to major humanitarian emergencies for 3 months. The following psychotropic medicines are included in ◆ the IEHK: Amitriptyline ▸ tablets: 25 mg tablet x 4000 Biperiden ▸ tablets: 2 mg tablet x 400 Diazepam ▸ tablets: 5 mg tablet x 240 Diazepam ▸ injections: 5 mg/ml, 2 ml/ampoule x 200 Haloperidol ▸ tablets: 5 mg tablet x 1300 Haloperidol ▸ injections: 5 mg/ml; 1 ml/ampoule x 20 Phenobarbital ▸ tablets: 50 mg x 1000. The quantity of medicines in the IEHK is not sufficient ◆ for programmes that proactively identify and manage epilepsy, psychosis and depression. Additional medicines will need to be ordered. Over the long term, the necessary quantities of ◆ medicines should be informed by actual use. I » n addition to psychotropic medicines, atropine should be available for the clinical management of acute pesticide intoxication, a common form of self-harm. Atropine is contained in the IEHK (1mg/ml, 1 ml/ampoule x 50). E » nsure that all medicines are stored securely. Information management Ensure confidentiality » . Health records should be stored securely. I » dentify data needed for input into the health information system. Consider using the UNHCR Health Information ◆ System’s 7-category neuropsychiatric component for guidance on documenting MNS disorders (see Annex 1). In large, acute emergencies, public health decision- ◆ makers may not be ready to add 7 items to the health information system. In such a situation, at the very least an item labelled “mental, neurological or substance use problem” should be added to the health information system. Over time this item should be replaced with a more detailed system. C » ollect and analyse the data and report the results to relevant public health decision-makers. 5G PC General Principles of Care for People with Mental, Neurological and Substance Use Conditions in Humanitarian Settings GPC 1. Principles of Communication In rapidly changing and unpredictable humanitarian environments, health-care providers are under enormous pressure to see as many people as possible in the shortest amount of time. Consultations in health facilities need to be brief, flexible and focused on the most urgent issues. Good communication skills will help health-care providers achieve these goals and will help deliver effective care to adults, adolescents and children with mental, neurological and substance use (MNS) conditions. Create an environment that facilitates open » communication Meet the person in a ◆ private space, if possible. Position yourself to be at the ◆ same eye level as the person (e.g. if the person is sitting, sit down too). Welcome ◆ the person; introduce yourself and your position/role in a culturally appropriate way. Acknowledge ◆ everyone present. Ask the person whether he/she wants their carers or ◆ other people to stay. Unless the person is a young child, suggest that you ▸ would like to talk to the person alone if possible. If the person wants others to stay, respect this. If you see the person alone, seek permission to ▸ ask the carers relevant assessment questions to ∙ find out their perspective, and involve the carers when the management plan is ∙ discussed and agreed. Let the person know that information discussed ◆ during the visit will be kept confidential and will not be shared without their permission, except when you perceive a risk to the person or to others (note that this message may need to be adapted according to national legal limits on confidentiality). Involve the person with the MNS condition as much » as possible Even if the person’s functioning is impaired, always ◆ try to involve them in the discussion. This is also true for children, youths and elderly people with MNS conditions. Do not ignore them by talking only with their carers. Always try to ◆ explain to the person what you are doing (e.g. during physical examination) and what you are going to do. Start by listening » Allow the person with an MNS condition to speak ◆ without interruption. Distressed people may not always give a clear history. When this happens, be patient and ask for clarification. Try not to rush them. Do not press the person to discuss or describe potentially ◆ traumatic events* if they do not wish to open up. Simply let them know that you are there to listen. Children may need more time to feel comfortable. ◆ Use language that they can understand. Establishing a relationship with children may require talking about their interests (toys, friends, school, etc.). Be clear and concise » Use language that the person is familiar with. Avoid ◆ using technical terms. Stress can impair people’s ability to process information. ◆ Provide one point at a time to help the person understand what is being said before moving on to the next point. Summarize ◆ and repeat key points. It can be helpful to ask the person or carers to write down important points. Alternatively, provide a written summary of the key points for the person. Respond with sensitivity when people disclose difficult » experiences (e.g. sexual assault, violence or self-harm) Let the person know that you will respect the ◆ confidentiality of the information. Never belittle the person’s feelings or preach or be ◆ judgemental. Acknowledge that it may have been difficult for the ◆ person to share. If referral to other services is necessary, explain clearly ◆ what the next steps will be. Seek the consent of the person to share information with other providers who may be able to help. For example: You have told me that your neighbour has done ▸ something very bad to you. I will not share this with anyone else but I can think of some people who may be able to help you. Is it OK if I discuss your experience with my colleague from agency X? Do not judge people by their behaviours » People with severe MNS conditions may demonstrate ◆ unusual behaviours. Understand that this may be because of their illness. Stay calm and patient. Never laugh at the person. If the person behaves inappropriately (e.g. ▸ agitated, aggressive, threatening), look for the source of the problem and suggest solutions. Involve their carers or other staff members in creating a calm, quiet space. If they are extremely distressed or agitated, you may need to prioritize their consultation and bring them into your consulting space at once. If needed, use appropriate interpreters » If needed, try to work with trained interpreters, ◆ preferably of the same gender as the person with the MNS condition. If a trained interpreter is not available, other health-care staff or carers may interpret, with the consent of the person. In situations where the carer interprets, be aware ◆ that the person with the MNS condition may not fully disclose. In addition, conflict of interest between the person and the carer may influence communication. If this becomes an issue, arrange for an appropriate interpreter for future visits. Instruct the interpreter to maintain confidentiality ◆ and translate literally, without adding their own thoughts and interpretations. 6G PC 2. Principles of Assessment Clinical assessment involves identifying the MNS condition as well as the person’s own understanding of the problem(s). It is important also to assess the person’s strengths and resources (e.g. social supports). This additional information will help health-care providers offer better care. It is important to always pay attention to the overall appearance, mood, facial expression, body language and speech of the person with an MNS condition during assessment. Explore the presenting complaint » What brings you here today? When and how did the ◆ problem start? How did it change over time? How do you feel about this problem? Where do you ◆ think it came from? How does this problem impact on your daily life? ◆ How does the problem affect you at school/work or in daily community life? What kind of things did you try to solve this problem? ◆ Did you try any medication? If so, what kind (e.g. prescribed, non-prescribed, herbal)? What effect did it have? Explore possible family history of MNS conditions » Do you know of anyone in your family who has had ◆ a similar problem? Explore the person’s general health history » Ask about any previous physical health problem: ◆ Have you had any serious health problem ▸ in the past? Do you have any health problem for which you are ▸ currently receiving care? Ask if the person is taking any medication: ◆ Has a health-care provider prescribed any ▸ medication you are supposed to be taking right now? What is the name of that medication? Did you ▸ bring it with you? How often do you take it? Ask if the person has ever had an allergic reaction ◆ to a medication. Explore current stressors, coping strategies and social » support How has your life changed since the … [state ◆ the event that caused the humanitarian crisis]? Have you lost a loved one? ◆ How severe is the stress in your life? ◆ How is it affecting you? What are your most serious problems right now? ◆ How do you deal/cope with these problems day ◆ by day? What kind of support do you have? Do you get help ◆ from family, friends or people in the community? Explore possible alcohol and drug use » Questions regarding alcohol and drugs can be perceived as sensitive and even offensive. However, this is an essential component of MNS assessment. Explain to the person that this is part of the assessment and try to ask questions in a non-judgemental and culturally sensitive way. I need to ask you a few routine questions as part of ◆ the assessment. Do you take alcohol (or any other substance known to be a problem in the area)? [If yes] How much per day/week? Do you take any tablets when you feel stressed, upset ◆ or afraid? Is there anything you use when you have pain? Do you take sleeping tablets? [If yes] How much/many do you take per day/week? Since when? Explore possible suicidal thoughts and suicide attempts » Questions regarding suicide may also be perceived as offensive, but they are also essential questions in an MNS assessment. Try to ask questions in a culturally sensitive and non-judgemental way. You may start with: ◆ What are your hopes for the future? If the person expresses hopelessness, ask further questions (>> Box 1 of SUI module), such as Do you feel that life is worth living? Do you think about hurting yourself? or Have you made any plans to end your life? (>> SUI) Conduct a targeted physical examination » This should be a focused physical examination, guided ◆ by the information found during the MNS assessment. If any physical condition is found at this stage, either manage or refer to appropriate resources. If an MNS condition is suspected, go to the relevant module for assessment. » If the person presents with features relevant to more than one MNS condition, » then all relevant modules need to be considered. 7G PC 3. Principles of Management Many MNS conditions are chronic, requiring long-term monitoring and follow-up. In humanitarian settings, however, continuity of care may be difficult because mental health care is not consistently available or people have been or are about to be displaced. Therefore, it is important to recognize the carers of people with MNS conditions as a valuable resource. They may be able to provide consistent care, support and monitoring throughout the crisis. Carers include anyone who shares responsibility for the well-being of the person with an MNS condition, including family, friends or other trusted people. Increasing the person’s and the carer’s understanding of the MNS condition, management plan and follow-up plan will enhance adherence. Manage both mental and physical conditions in people » with MNS conditions Provide information about the condition to the ◆ person If the person agrees, also provide the information ▸ to the carer. Discuss and determine achievable goals, and develop ◆ and agree on a management plan with the person If the person agrees, also involve the carer in this ▸ discussion For the proposed management plan, provide ▸ information on: expected benefits of treatment; ∙ duration of treatment; ∙ importance of adhering to treatment, ∙ including practising any relevant psychological interventions (e.g. relaxation training) at home and how carers could help; potential side-effects of any medication being ∙ prescribed; potential involvement of social workers, case ∙ managers, community health workers or other trusted members in the community (>> Principles of Reducing Stress and Strengthening Social Support below); prognosis. Maintain a hopeful tone, but be ∙ realistic about recovery. Provide information about the financial aspects of ◆ the management plan, if relevant. Address the person’s and the carer’s questions and » concerns about the management plan If the person is pregnant or breastfeeding: Avoid prescribing medications that may » have potential risks to the fetus, and facilitate access to antenatal care. Avoid prescribing medications that may » have potential risks to the infant/toddler of a breastfeeding woman. Monitor the baby of a breastfeeding woman who is on any medication. Consider facilitating access to baby-friendly spaces/tents. Before the person leaves: » Confirm that the person and the carer understand ◆ and agree on the management plan (e.g. you may ask both to repeat the essentials of the plan). Encourage self-monitoring of the symptoms and ◆ educate the person and carer on when to seek urgent care. Arrange a follow-up visit. ◆ Create a follow-up plan, taking into consideration ▸ the current humanitarian situation (e.g. fleeing/ moving population and disruptions in services). If the person is unlikely to be able to access the ▸ same clinic: Provide a brief written management plan and ∙ encourage the person to take this to any future clinical visits. Provide contact information for other health- ∙ care facilities nearby. Initial follow-up visits should be more frequent until ◆ the symptoms begin to respond to treatment. Once the symptoms start improving, less frequent but ◆ regular appointments are recommended. Explain that the person can return to the clinic at any ◆ time in between follow-up visits if needed (e.g. when experiencing side-effects of medications). At each follow-up meeting, assess for: » Response to treatment, medication side-effects ◆ and adherence to medications and psychosocial interventions. Acknowledge all progress towards the goals and reinforce adherence. General health status. Monitor physical health ◆ regularly. Self-care (e.g. diet, hygiene, clothing) and functioning ◆ in the person’s own environment. Psychosocial issues and/or change in living conditions ◆ that can affect management. The person’s and the carer’s understanding ◆ and expectations of the treatment. Correct any misconceptions. Always check the latest contact information, as it can ◆ change frequently. During the entire follow-up period: » Maintain regular contact with the person and their ◆ carer. If available, assign a community worker or another trusted person in the community to keep in touch with the person. This person may be a family member. Have a plan of action for when the person does not ◆ show up. Try to find out why the person did not return. ▸ A community worker or another trusted person can help locate the person (e.g. home visits). If possible, try to address the issue so that the ▸ person can return to the clinic. Consult a specialist if the person does not improve. ◆ 8G PC 4. Principles of Reducing Stress and Strengthening Social Support Reducing stress and strengthening social support is an integral part of MNS treatment in humanitarian settings, where people often experience extremely high levels of stress. This includes not only the stress felt by people with MNS conditions but also the stress felt by their carers and dependants. Stress often contributes to or worsens existing MNS conditions. Social support can diminish many of the adverse effects of stress; therefore, attention to social support is essential. Strengthening social support is also an essential component of protection (>> Principles of Protection of Human Rights) and overall well- being of the population affected by humanitarian crises (>> Principles of Attention to Overall Well-Being). Explore possible stressors and the availability of social » support What is your biggest worry these days? ◆ How do you deal with this worry? ◆ What are some of the things that give you comfort, ◆ strength and energy? Who do you feel most comfortable sharing your ◆ problems with? When you are not feeling well, who do you turn to for help or advice? How is your relationship with your family? In what ◆ way do your family and friends support you and in what way do you feel stressed by them? Be aware of signs of abuse or neglect » Be attentive to potential signs of sexual or physical ◆ abuse (including domestic violence) in women, children and older people (e.g. unexplained bruises or injuries, excessive fear, reluctance to discuss matters when a family member is present). Be attentive to potential signs of neglect, particularly ◆ in children, people living with disability and older people (e.g. malnourishment in a family with access to sufficient food, a child who is overly withdrawn). When signs of abuse or neglect are present, interview ◆ the person in a private space to ask if anything hurtful is going on. If you suspect abuse or neglect: ◆ Talk immediately with your supervisor to discuss ▸ the plan of action. With the person’s consent, identify community ▸ resources (e.g. trusted legal services and protection networks) for protection. Based on information gathered, consider the following » strategies: Problem-solving: ◆ Use problem-solving techniques* to help the person ▸ address major stressors. When stressors cannot be solved or reduced, problem-solving techniques may be used to identify ways to cope with the stressor. In general, do not give direct advice. Try to encourage the person to develop their own solutions. When working with children and adolescents, it is ▸ essential to assess and address the carer’s sources of stress as well. Strengthen social support: ◆ Help the person to identify supportive and trusted ▸ family members, friends and community members and to think through how each one can be involved in helping. With the person’s consent, refer them to other ▸ community resources for social support. Social workers, case managers or other trusted people in the community may be able to assist in connecting the person with appropriate resources such as: social or protection services ∙ shelter, food and non-food items ∙ community centres, self-help and support groups ∙ income-generating activities and other ∙ vocational activities formal/informal education ∙ child-friendly spaces or other structured activities ∙ for children and adolescents. When making a referral, help the person to access them (e.g. provide directions to the location, operating hours, telephone number, etc.) and provide the person with a short referral note. Teach stress management: ◆ Identify and develop positive ways to relax ▸ (e.g. listening to music, playing sports, etc.). Teach the person and the carers specific stress ▸ management techniques (e.g. breathing exercises (>> Box GPC 2)). In some settings, you can refer to a health worker ∙ (e.g. nurse or psychosocial worker) who can teach these techniques. Address stress of the carers » Ask the carer(s) about: ◆ worries and anxiety around caring for the person ▸ with MNS conditions in the current humanitarian emergency situation; practical challenges (e.g. burden on the carers’ ▸ time, freedom, money); ability to carry out other daily activities, such as ▸ work or participation in community events; physical fatigue; ▸ social support available to the carers: ▸ Are there other people who can help you when ∙ you are not able to care for the person (for example, when you are sick or very tired)?; psychological well-being. If carers seem distressed ▸ or unstable, assess them for MNS conditions (e.g. >> DEP, SUB). After the assessment, try to address the carers’ needs ◆ and concerns. This may involve: giving information; ▸ linking the carer with relevant community services ▸ and supports; discussing respite care. Another family member ▸ or a suitable person can take over the care of the person temporarily while the main carer takes a rest or carries out other important activities; performing problem-solving counselling* and ▸ teaching stress management; managing any MNS conditions identified in the carer. ▸ Acknowledge that it is stressful to care for people ◆ with MNS conditions, but tell the carer that it is important that they continue to do so. Even when this is difficult, carers need to respect the dignity of the people they care for and involve them in making decisions about their own lives as much as possible. 9G PC Box GPC 1: Strengthening community supports In addition to clinical management, encourage activities that enhance family and community support for everyone, especially marginalized community members. For further guidance, see Understanding Community- Based Protection (UNHCR, 2013) and Action Sheet 5.2 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). Box GPC 2: Relaxation exercise: instructions for slow breathing technique I am going to teach you how to breathe in a way that will help relax your body and your mind. It will take some practice before you feel the full benefits of this breathing technique. The reason this strategy focuses on breathing is because when we feel stressed our breathing becomes fast and shallow, making us feel tenser. To begin to relax, you need to start by changing your breathing. Before we start, we will relax the body. Gently shake and loosen your arms and legs. Let them go floppy and loose. Roll your shoulders back and gently move your head from side to side. Now place one hand on your belly and the other hand on your upper chest. I want you to imagine you have a balloon in your stomach and when you breathe in you are going to blow that balloon up, so your stomach will expand. And when you breathe out, the air in the balloon will also go out, so your stomach will flatten. Watch me first. I am going to exhale first to get all the air out of my stomach. [Demonstrate breathing from the stomach – try and exaggerate the pushing out and in of your stomach] OK, now you try to breathe from your stomach with me. Remember, we start by breathing out until all the air is out; then breathe in. If you can, try and breathe in through your nose and out through your mouth. Great! Now the second step is to slow the rate of your breathing down. So we are going to take three seconds to breathe in, then two seconds to hold your breath, and three seconds to breathe out. I will count with you. You may close your eyes or keep them open. OK, so breathe in, 1, 2, 3. Hold, 1, 2. And breathe out, 1, 2, 3. Do you notice how slowly I count? [Repeat this breathing exercise for approximately one minute] That’s great. Now when you practise on your own, don’t be too concerned about trying to keep exactly to three seconds. Just try your best to slow your breathing down when you are stressed. OK, now try on your own for one minute. 10 G PC 5. Principles of Protection of Human Rights People with severe MNS conditions need protection since they are at higher risk of human rights violations. They often experience difficulties in taking care of themselves and their families in addition to facing discrimination in many areas of life, including work, housing and family life. They may have poor access to humanitarian aid. They may experience abuse or neglect in their own families and are often denied opportunities to fully participate in the community. Some people with severe MNS conditions may not be aware that they have a problem that requires care and support. People with MNS conditions may experience a range of human rights violations during humanitarian emergencies, including: Discrimination » in access to basic needs for survival such as food, water, sanitation, shelter, health services, protection and livelihood support; Denial of the right to exercise legal capacity; » Lack of access to services for their specific needs; » Physical and sexual abuse, exploitation, violence, neglect and arbitrary detention; » Abandonment or separation from family during displacement; » Abandonment and neglect in institutional settings. » Unfortunately, community protection systems and disability programmes do not always include, and sometimes even actively exclude, protection of people with severe MNS conditions. Health-care providers should therefore actively advocate for and address the gap in protection of these people. Below are key actions to address the protection of people with MNS conditions living in communities in humanitarian settings. Engage the key stakeholders » Identify key stakeholders who should be made aware ◆ of the protection issues surrounding people with MNS conditions. These key stakeholders include: people with MNS conditions and their carers; ▸ community leaders (e.g. elected community ▸ representatives, community elders, teachers, religious leaders, traditional and spiritual healers); managers of various services (e.g. protection/ ▸ security, health, shelter, water and sanitation, nutrition, education, livelihood programmes); managers of disability services (many disability ▸ services inadvertently overlook disability due to MNS conditions); representatives of community groups (youth or ▸ women’s groups) and human rights organizations; police and legal authorities. Organize awareness-raising activities for the key ◆ stakeholders: Consider offering orientation workshops on MNS ▸ conditions. Consult people with MNS conditions, their carers ▸ and the disability and social service sectors in the design and implementation of awareness-raising activities. During the awareness raising activities: ▸ Educate and dispel misconceptions about people ∙ with MNS conditions. Educate on the rights of people with ∙ MNS conditions, including equal access to humanitarian aid and protection. Dispel discrimination against people with MNS ∙ conditions. Advocate for support for the carers of people ∙ with MNS conditions. Protect the rights of people with severe MNS conditions » in health-care settings Always treat people with MNS conditions with respect ◆ and dignity. Ensure that people with MNS conditions have the ◆ same access to physical health care as people without MNS conditions. Respect a person’s right to refuse health care unless ◆ they lack the capacity to make that decision (cf. signed international conventions). Discourage institutionalization. If the person is ◆ already institutionalized, advocate for their rights in the institutional setting. Promote the integration of people with severe MNS » conditions in the community Advocate for the inclusion of people with MNS ◆ conditions in livelihood supports, protection programmes and other community activities. Advocate for the inclusion of children with epilepsy ◆ and other MNS conditions in mainstream education. Advocate for the inclusion of programmes for ◆ children and adults with intellectual disabilities/ developmental delay in community disability support programmes. Advocate for maintaining, as far as possible, ◆ autonomy and independence for people with MNS conditions. General principles of protection in humanitarian action are described in the Sphere Handbook (Sphere Project, 2011). For additional guidance on the protection of people in mental hospitals/institutions, see Action Sheet 6.3 of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). 11 G PC 6. Principles of Attention to Overall Well-being In addition to clinical care, people with MNS conditions need a range of other supports for their overall well-being. This is especially true in humanitarian settings where basic services, social structures, family life and security are often disrupted. People with MNS conditions face extra challenges to their daily routines and basic self-care. The role of health-care providers extends beyond clinical care to advocacy for the overall well-being of people with MNS conditions across multiple sectors, as shown in the IASC Guidelines pyramid (see figure GPC 1). Support people with MNS conditions to safely access » services necessary for survival and for a dignified way of living (e.g. water, sanitation, food aid, shelter, livelihoods support). This may involve: advising about the availability and location of such ◆ services; actively referring and working with the social sector ◆ to connect people to social services (e.g. social work- type case management); advising about security issues when the person is not ◆ sufficiently aware of threats to security. Arrange priority access to relevant activities for people » with MNS conditions, such as helping children with such conditions to access child-friendly spaces. Support the general physical health of people with » MNS conditions: Arrange regular health assessments and vaccinations. ◆ Advise about basic self-care (nutrition, physical ◆ activity, safe sex, family planning, etc.). Figure GPC 1. The IASC intervention pyramid for mental health and psychosocial support in emergencies (adapted with permission) Clinical services Focused psychosocial supports Strengthening community and family supports Social considerations in basic services and security Examples: Clinical mental health care (whether by PHC staff or mental health professionals) Basic emotional and practical support to selected individuals or families Activating social networks Supportive child-friendly spaces Advocacy for good humanitarian practice: basic services that are safe, socially appropriate and that protect dignity

13 A C U Acute Stress ACU In humanitarian emergencies, adults, adolescents and children are often exposed to potentially traumatic events*. Such events trigger a wide range of emotional, cognitive, behavioural and somatic reactions. Although most reactions are self-limiting and do not become a mental disorder, people with severe reactions are likely to present to health facilities for help. In many humanitarian emergencies people suffer various combinations of potentially traumatic events and losses; thus they may suffer from both acute stress and grief. The symptoms, assessment and management of acute stress and grief have much in common. However, grief is covered in a separate module (>> GRI). After a recent potentially traumatic event, clinicians need to be able to identify the following: Significant symptoms of acute stress (ACU). » People with these symptoms may present with a wide range of non-specific psychological and medically unexplained physical complaints. These symptoms include reactions to a potentially traumatic event within the last month, for which people seek help or which causes considerable difficulty with daily functioning, and which does not meet the criteria for other conditions covered in this guide. The present module covers assessment and management of significant symptoms of acute stress. Post-traumatic stress disorder » (>> PTSD). When a characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event and if it causes considerable difficulty with daily functioning, the person may have developed post-traumatic stress disorder. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. potentially traumatic events) but that could also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), suicide (>> SUI) and other significant mental health complaints (>> OTH). Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs. 14 A C U Assessment question 2: If a potentially traumatic event has occurred within the last month, does the person have significant symptoms of acute stress? C » heck for: anxiety about threats related to the traumatic ◆ event(s) sleep problems ◆ concentration problems ◆ recurring frightening dreams, flashbacks* or intrusive ◆ memories* of the events, accompanied by intense fear or horror deliberate avoidance of thoughts, memories, activities ◆ or situations that remind the person of the events (e.g. avoiding talking about issues that are reminders, or avoiding going back to places where the events happened) being “jumpy” or “on edge”; excessive concern and ◆ alertness to danger or reacting strongly to loud noises or unexpected movements feeling shocked, dazed or numb, or inability to feel ◆ anything any disturbing emotions (e.g. frequent tearfulness, ◆ anger) or thoughts changes of behaviour such as: ◆ aggression ▸ social isolation and withdrawal ▸ risk-taking behaviours in adolescents ▸ regressive behaviour* such as bedwetting, ▸ clinginess or tearfulness in children hyperventilation (e.g. rapid breathing, shortness of ◆ breath) medically unexplained physical complaints, such as: ◆ palpitations, dizziness ▸ headaches, generalized aches and pains ▸ dissociative symptoms relating to the body (e.g. ▸ medically unexplained paralysis*, inability to speak or see, “pseudoseizures”*). S » ignificant symptoms of acute stress stress are likely if the person meets all of the following criteria: a potentially traumatic event has occurred ◆ within approximately 1 month the symptoms started ◆ after the event considerable difficulty with daily functioning because ◆ of the symptoms or seeking help for the symptoms. Ask if the person has experienced a » potentially traumatic event. A potentially traumatic event is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, or major accidents or injuries. Consider asking: What major stress have you experienced? Has your ◆ life been in danger? Have you experienced something that was very frightening or horrific or has made you feel very bad? Do you feel safe at home? Ask » how much time has passed since the event(s). Go » to assessment question 2 if a potentially traumatic event has occurred within the last month. If » a major loss (e.g. the death of a loved one) has occurred, also assess for grief (>> GRI). If » a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide (>> DEP, PTSD, PSY, SUB). Assessment Assessment question 1: Has the person recently experienced a potentially traumatic event? Assessment question 3: Is there a concurrent condition? Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any other » mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 15 A C U Basic Management Plan 1. In ALL cases: Offer » additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care): Address ◆ current psychosocial stressors. Strengthen social support. ◆ Teach stress management. ◆ E » ducate the person about normal reactions to grief and acute stress, e.g.: People often have these reactions after such events. ◆ In most cases, reactions will reduce over time. ◆ M » anage concurrent conditions. DO NOT prescribe medications to manage symptoms of acute stress (unless otherwise noted below). 2. In case of sleep problems as a symptom of acute stress, offer the following additional management: Explain that people commonly develop sleep problems » (insomnia) after experiencing extreme stress. Explore » and address any environmental causes of insomnia (e.g. noise). E » xplore and address any physical cause of insomnia (e.g. physical pain). A » dvise on sleep hygiene, including regular sleep routines (e.g. regular times for going to bed and waking up), avoiding coffee, nicotine and alcohol late in the day or before going to bed. Emphasize that alcohol disturbs sleep. E » xceptionally, in extremely severe cases where psychologically oriented interventions (e.g. relaxation techniques) are not feasible or not effective, and insomnia causes considerable difficulty with daily functioning, short-term (3–7 days) treatment with benzodiazepines may be considered. Dose: ◆ For adults, prescribe 2–5 mg of diazepam at ▸ bedtime. For older people, prescribe 1–2.5 mg of diazepam ▸ at bedtime. Check for drug-drug interactions before ▸ prescribing diazepam. Common side-effects of benzodiazepines include ▸ drowsiness and muscle weakness. Caution: benzodiazepines can slow down ▸ breathing. Regular monitoring may be necessary. Caution: benzodiazepines may cause dependence*. ▸ Use only for short-term treatment. Note: ◆ This treatment is for adults only. ▸ Do not prescribe benzodiazepines to children or ▸ adolescents. Avoid this medication in women who are pregnant ▸ or breastfeeding. Monitor for side-effects frequently when using ▸ this medication in older people. This is a temporary solution for an extremely ▸ severe sleep problem. Benzodiazepines should not be used for insomnia ▸ caused by bereavement in adults or children. Benzodiazepines should not be used for any other ▸ symptoms of acute stress or PTSD. 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Provide basic psychosocial support » 3 Listen ◆ carefully. DO NOT pressure the person to talk. Ask ◆ the person about his/her needs and concerns. Help ◆ the person to address basic needs, access services and connect with family and other social supports. Protect ◆ the person from (further) harm. 16 A C U 3. In the case of bedwetting in children as a symptom of acute stress, offer the following additional management: Obtain the history of bedwetting to confirm that it » started after experiencing a stressful event. Rule out and manage other possible causes (e.g. urinary tract infection). Explain » : Bedwetting is a ◆ common, harmless reaction in children who experience stress. Children ◆ should not be punished for bedwetting because punishment adds to the child’s stress and may make the problem worse. The carer should avoid embarrassing the child by mentioning bedwetting in public. Carers should remain calm and emotionally ◆ supportive. Consider training carers on the use of simple » behavioural interventions (e.g. rewarding avoidance of excessive fluid intake before sleep, rewarding toileting before sleep, rewarding dry nights). The reward can be anything the child likes, such as extra playtime, stars on a chart or local equivalent. 4. In the case of hyperventilation (breathing extremely fast and uncontrollably) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if hyperventilation started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes such as lung disease. If » no physical cause is identified, reassure the person that hyperventilation sometimes occurs after experiencing extreme stress and that it is unlikely to be a serious medical problem. B » e calm and remove potential sources of anxiety if possible. Help the person regain normal breathing by practising slow breathing (>> Principles of Reducing Stress and Strengthening Social Support in General Principles of Care) (do not recommend breathing into a paper bag). 5. In the case of a dissociative symptom relating to the body (e.g. medically unexplained paralysis, inability to speak or see, “pseudoseizures”) as a symptom of acute stress, offer the following additional management: Rule out and manage » other possible causes, even if the symptoms started immediately after a stressful event. Always conduct necessary medical investigations to identify possible physical causes. See epilepsy module for guidance on medical investigations relevant to seizures/convulsions (>> EPI). Acknowledge » the person’s suffering and maintain a respectful attitude. Avoid reinforcing any gain that the person may get from the symptoms. As » k for the person’s own explanation of the symptoms and apply the general guidance on the management of medically unexplained somatic symptoms (>> OTH). R » eassure the person that these symptoms sometimes develop after experiencing extreme stress and that it is unlikely to be a serious medical problem. Co » nsider the use of culturally specific interventions that do no harm. 6. Ask the person to return in 2–4 weeks if the symptoms do not improve, or at any time if the symptoms get worse. 17 G R I Grief GRI In humanitarian emergencies, adults, adolescents and children are often exposed to major losses. Grief is the emotional suffering people feel after a loss. Although most reactions to loss are self-limiting without becoming a mental disorder, people with significant symptoms of grief are more likely to present to health facilities for help. After a loss, clinicians need to be able to identify the following: Significant symptoms of grief (GRI). » As with similar to symptoms of acute stress, people who are grieving may present with a wide range of non-specific psychological and medically unexplained physical complaints. People have significant symptoms of grief after a loss if the symptoms cause considerable difficulty with daily functioning (beyond what is culturally expected) or if people seek help for the symptoms. The present module covers assessment and management of significant symptoms of grief. Prolonged grief disorder. » When significant symptoms of grief persist over an extended period of time, people may develop prolonged grief disorder. This condition involves severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in the person’s culture). In these cases, health providers need to consult a specialist. Problems and disorders that are more likely to occur after exposure » to stressors (e.g. bereavement) but that also occur in the absence of such exposure. These include: moderate-severe depressive disorder (>> DEP), psychosis (>> PSY), harmful use of alcohol and drugs (>> SUB), self-harm/suicide (>> SUI) and other significant mental health complaints (>> OTH) Reactions that are not clinically significant and that do not require clinical » management. Of all reactions, these are the most common. They include transient reactions for which people do not seek help and which do not impair day-to-day functioning beyond what is culturally expected. In these cases, health providers need to be supportive, help address the person’s needs and concerns and monitor whether expected natural recovery occurs; however, such reactions do not require clinical management. 18 G R I Assessment question 2: If a major loss has occurred within the last 6 months,4 does the person have significant symptoms of grief? C » heck for: sadness, anxiety, anger, despair ◆ yearning and preoccupation with loss ◆ intrusive memories*, images and thoughts of the ◆ deceased loss of appetite ◆ loss of energy ◆ sleep problems ◆ concentration problems ◆ social isolation and withdrawal ◆ medically unexplained physical complaints (e.g. ◆ palpitations, headaches, generalized aches and pains) culturally specific grief reactions (e.g. hearing the ◆ voice of the deceased person, being visited by the deceased person in dreams). S » ignificant symptoms of grief are likely if the person meets all of the following criteria: one or more losses within approximately 6 months ◆ any of the above symptoms that started after the loss ◆ considerable difficulty with daily functioning because ◆ of the symptoms (beyond what is culturally expected) or seeking help for the symptoms. Assessment question 3: Is there a concurrent condition? Ask if the person has experienced a » major loss. Consider asking: How has the disaster/conflict affected you? ◆ Have you lost family or friends? Your house? Your ◆ money? Your job or livelihood? Your community? How has the loss affected you? ◆ Are any family members or friends missing? ◆ Ask » how much time has passed since the event(s). G » o to assessment question 2 if a major loss has occurred within the last 6 months. If » a major loss has occurred more than 6 months ago or if a potentially traumatic event has occurred more than 1 month ago, then consider other conditions covered in this guide ( >> DEP, PTSD, PSY, SUB) or prolonged grief disorder. Assessment Assessment question 1: Has the person recently experienced a major loss? 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. Check for any » physical conditions that may explain the symptoms, and manage accordingly if found. Check for any » other mental, neurological and substance use (MNS) condition (including depression) covered in this guide that may explain the symptoms and manage accordingly if found. 19 G R I Basic Management Plan 1. Provide basic psychosocial support5 Help » the person to address basic needs, access services and connect with family and other social supports. Protect » the person from (further) harm. DO NOT prescribe medications to manage symptoms of grief. 2. Offer additional psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address » current psychosocial stressors. Strengthen » social support. Teach » stress management. 3. Educate the person about common reactions to losses, e.g.: Ask if appropriate mourning ceremonies/rituals have » occurred or have been planned. If this is not the case, discuss the obstacles and how they can be alleviated. Find out what has happened to the body. If the body is » missing, help trace or identify the remains. If the body cannot be found, discuss alternative ways to » preserve memories, such as memorials. 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Listen » carefully. DO NOT pressure the person to talk. Ask » the person about his/her needs and concerns. People may react in different ways after major losses. » Some people show strong emotions while others do not. Crying » does not mean you are weak. People » who do not cry may feel the emotional pain just as deeply but have other ways of expressing it. You » may think that the sadness and pain you feel will never go away, but in most cases, these feelings lessen over time. Sometime » s a person may feel fine for a while, then something reminds them of the loss and they may feel as bad as they did at first. This is normal and again these experiences become less intense and less frequent over time. There » is no right or wrong way to feel grief. Sometimes you might feel very sad, and at other times you might be able to enjoy yourself. Do not criticise yourself for how you feel at the moment. 4. Manage concurrent conditions. 5. Discuss and support culturally appropriate adjustment/mourning* processes 6. If feasible and culturally appropriate, encourage early return to previous, normal activities (e.g. at school or work, at home or socially). 7. For the specific management of sleep problems, bedwetting, hyperventilation and dissociative symptoms after recent loss, see the relevant sections in the module on acute stress (>> ACU). 20 G R I 8. If the person is a young child: Answer the child’s questions by providing clear and » honest explanations that are appropriate to the child’s level of development. Do not lie when asked about a loss (e.g. Where is my mother?). This will create confusion and may damage the person’s trust in the health provider. Check for and correct “magical thinking” common in » young children ( e.g. children may think that they are responsible for the loss; for example, they may think that their loved one died because they were naughty or because they were upset with them). 9. For children, adolescents and other vulnerable persons who have lost parents or other carers, address the need for protection and ensure consistent, supportive caregiving, including socio-emotional support. If needed, connect the person to trusted protection » agencies/networks. 10. If prolonged grief disorder is suspected, consult a specialist for further assessment and management. 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. The person may have prolonged grief disorder » if the symptoms of bereavement include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months.6 11. Ask the person to return in 2–4 weeks if the symptoms do not improve or at any time if the symptoms get worse. 21 D EP Moderate-severe Depressive Disorder DEP Moderate-severe depressive disorder may develop in adults, adolescents and children who have not been exposed to any particular stressor. In any community there will be people suffering from moderate-severe depressive disorder. However, the significant losses and stress experienced during humanitarian emergencies may result in grief, fear, guilt, shame and hopelessness, increasing the risk of developing moderate-severe depressive disorder. Nevertheless, these emotions may also be normal reactions to recently experienced adversity. Management for moderate-severe depressive disorder should only be considered if the person has persistent symptoms over a number of weeks and as a result has considerable difficulties carrying out daily activities. Typical presenting complaints of moderate-severe depressive disorder: Low energy, fatigue, sleep problems Multiple persistent physical symptoms with no clear cause (e.g. aches and pains) Persistent sadness or depressed mood, anxiety Little interest in or pleasure from activities. 22 D EP Assessment Assessment question 1: Does the person have moderate-severe depressive disorder? Assessment question 3: Is there a concurrent mental, neurological and substance use (MNS) condition requiring management? Assess for the following: » 7 The person has had at least one of the following core A. symptoms of depressive disorder for at least 2 weeks: Persistent depressed mood ◆ For children and adolescents: either irritability or ▸ depressed mood Markedly diminished interest in or pleasure from ◆ activities, including those that were previously enjoyable The latter may include reduced sexual desire. ▸ The person has had at least several of the following B. additional symptoms of depressive disorder to a marked degree (or many of the listed symptoms to a lesser degree) for at least 2 weeks: Disturbed sleep ◆ or sleeping too much Significant ◆ change in appetite or weight (decrease or increase) Beliefs of ◆ worthlessness or excessive guilt Fatigue ◆ or loss of energy Reduced ability to concentrate ◆ and sustain attention on tasks Indecisiveness ◆ Observable ◆ agitation or physical restlessness Talking or moving more slowly ◆ than normal Hopelessness ◆ about the future Suicidal ◆ thoughts or acts. The individual has considerable difficulty with daily C. functioning in personal, family, social, educational, occupational or other important domains. If » A, B and C – all 3 – are present for at least 2 weeks, then moderate-severe depressive disorder is likely. Delusions* or hallucinations* may be present. ◆ Check for these. If present, treatment for depressive disorder needs to be adapted. Consult a specialist. If » the person’s symptoms do not meet the criteria for moderate-severe depressive disorder, go to >> OTH module for assessment and management of the presenting complaint. Assessment question 2: Are there other possible explanations for the symptoms (other than moderate-severe depressive disorder)? Rule out concurrent physical conditions that can » resemble depressive disorder. Rule out and manage anaemia, malnutrition, ◆ hypothyroidism*, stroke and medication side-effects (e.g. mood changes from steroids*). Rule » out a history of manic episode(s). Assess if there has been a period in the past ◆ when several of the following symptoms occurred simultaneously: decreased need for sleep ▸ euphoric, expansive or irritable mood ▸ racing thoughts; being easily distracted ▸ increased activity, feeling of increased energy ▸ or rapid speech impulsive or reckless behaviours such as excessive ▸ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ▸ Assess to what extent the symptoms impaired ◆ functioning or were a danger to the person or to others. For example: Was your excessive activity a problem for you ▸ or your family? Did anybody try to hospitalize or confine you during that time because of your behaviour? There is a history of manic episode(s) if both ◆ the following occurred: Several of the above 6 symptoms were present ▸ for longer than 1 week. The symptoms caused significant difficulty with ▸ daily functioning or were a danger to the person or to others. If a manic episode has ever occurred, then the ◆ depression is likely to be part of another disorder called bipolar disorder* and requires different management (>> Box DEP 2 at the end of this module). R » ule out normal reactions to major loss (e.g. bereavement, displacement) (>> GRI). The reaction is more likely to be a normal reaction ◆ to major loss if: There is ▸ marked improvement over time without clinical intervention; None of the following symptoms is present ▸ : beliefs of worthlessness ∙ suicidal ideation ∙ talking or moving more slowly than normal ∙ psychotic symptoms (delusions or hallucinations); ∙ There is ▸ no previous history of depressive disorder or manic episode; and Symptoms do not cause considerable difficulty ▸ with daily functioning. Exception: impaired functioning can be part of ∙ a normal response after bereavement when it is within cultural norms. R » ule out prolonged grief disorder: symptoms include severe preoccupation with or intense longing for the deceased person accompanied by intense emotional pain and considerable difficulty with daily functioning for at least 6 months (and for a period that is much longer than what is expected in that person’s culture). Consult a specialist if this disorder is suspected. Assess for » thoughts or plans of self-harm or suicide (>> SUI). Assess » for harmful alcohol or drug use (>> SUB). If a concurrent MNS condition is found, manage the » condition and moderate-severe depressive disorder at the same time. 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. 23 D EP Basic Management Plan Psychosocial interventions 1. Offer psychoeducation K » ey messages to the person and the carers: Depression is a very common condition that can ◆ happen to anybody. The occurrence of depression does not mean that the ◆ person is weak or lazy. The negative attitudes of others (e.g. “You should be ◆ stronger”, “Pull yourself together”) may relate to the fact that depression is not a visible condition (unlike a fracture or a wound) and the false idea that people can easily control their depression by sheer force of will. People with depression tend to have unrealistically ◆ negative opinions about themselves, their life and their future. Their current situation may be very difficult, but depression can cause unjustified thoughts of hopelessness and worthlessness. These views are likely to improve once the depression improves. Even if it is difficult, the person should try to do ◆ as many of the following as possible, as they can all help to improve mood: Try to start again (or continue) activities that were ▸ previously pleasurable. Try to maintain regular sleeping and waking times. ▸ Try to be as physically active as possible. ▸ Try to eat regularly despite changes in appetite. ▸ Try to spend time with trusted friends and family. ▸ Try to participate in community and other social ▸ activities as much as possible. The person should be aware of thoughts of self-harm ◆ or suicide. If they notice these thoughts, they should not act on them, but should tell a trusted person and come back for help immediately. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social supports. Try to reactivate the person’s previous social ◆ networks. Identify prior social activities that, if reinitiated, would have the potential for providing direct or indirect psychosocial support (e.g. family gatherings, visiting neighbours, community activities). Teach » stress management. 3. If trained and supervised therapists are available, consider encouraging people with moderate-severe depression to use one of the following brief psychological treatments whenever they are available: problem-solving counselling* » interpersonal therapy (IPT)* » There is increasing evidence that brief psychological treatments for depression can be done by trained and supervised lay/community workers. cognitive behavioural therapy (CBT)* » behavioural acti » vation*. 24 D EP 2. If it is decided to prescribe antidepressants, choose an appropriate antidepressant (>> Table DEP 1) Choose the antidepressant based on the person’s age, » concurrent medical conditions and drug side-effect profile (>> Table DEP 1). In » adolescents 12 years and older: Consider ◆ fluoxetine (but no other selective serotonin reuptake inhibitors (SSRI) or tricyclic antidepressants (TCAs)) only if symptoms persist or worsen despite psychosocial interventions. In » pregnant or breastfeeding women: Avoid antidepressants if possible. Consider ◆ antidepressants at the lowest effective dose if there is no response to psychosocial interventions. If the woman is breastfeeding, avoid fluoxetine. Consult a specialist, if available. In » elderly people: Avoid amitriptyline if possible. ◆ In people with » cardiovascular disease: Do not prescribe amitriptyline. ◆ In adults with » thoughts or plans of suicide: Fluoxetine ◆ is the first choice. If there is an imminent risk of self-harm or suicide (>> SUI), only give a limited supply of antidepressants (e.g. one week of supply at a time). Ask the person’s carers to keep and monitor medications and to follow up frequently to prevent medication overdose. Table DEP 1: Antidepressants Amitriptylinea (a TCAb) Fluoxetine (an SSRIc) Starting dose for adults 25–50 mg at bedtime 10 mg once per day. Increase to 20 mg after 1 week Starting dose for adolescents Not applicable (do not prescribe TCAsin adolescents) 10 mg once per day Starting dose for elderly and medically ill 25 mg at bedtime 10 mg once per day Dose increment for adults Increase by 25–50 mg per week If no response in 6 weeks, increaseto 40 mg once per day Typical effective dose in adults 100–150 mg (max. dose 300 mg)d 20–40 mg (max. dose 80 mg) Typical effective dose in adolescents, elderly and medically ill 50–75 mg (max. dose 100 mg) Do not prescribe in adolescents 20 mg (max. dose 40 mg) Serious and rare side effects Cardiac arrhythmia Prolonged akathisia* Bleeding abnormalities in those who use aspirin or other non-steroid anti-inflammatory drugs* Ideas of self-harm (especially in adolescents and young adults) Common side-effects Orthostatic hypotension (risk of fall), dry mouth, constipation, difficulty urinating, dizziness, blurred vision and sedation Headache, restlessness, nervousness, gastrointestinal disturbances, reversible sexual dysfunction Caution Stop immediately if the person developsa manic episode Stop immediately if the person develops a manic episode a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). Pharmacological interventions 1. Consider antidepressants In » children younger than 12: Do not ◆ prescribe antidepressants. In » adolescents 12–18 years of age: Do not ◆ consider antidepressants as first-line treatment. Offer psychosocial interventions first. In » adults: If the person has a ◆ concurrent physical condition that can resemble depressive disorder (>> Assessment question 2), always manage that condition first. Consider prescribing antidepressants if the depressive disorder does not improve after managing the concurrent physical conditions. If you suspect the symptoms are ◆ normal reactions to a major loss (>> Assessment question 2), do not prescribe antidepressants. Discuss with the person and decide together whether ◆ to prescribe antidepressants. Explain: Antidepressants are not addictive. ▸ It is very important to take the medication every ▸ day as prescribed. Some side-effects ▸ (>> Table DEP 1) may be experienced within the first few days but they usually resolve. It usually takes several weeks before improvements ▸ in mood, interest or energy can be noticed. Antidepressant medication usually needs to be continued ◆ for at least 9–12 months after the person feels well. Medications should not be stopped just because ◆ the person has experienced some improvement (it is not like a painkiller for headaches). Educate the person on the recommended timeframe for the medication. 25 D EP 3. Follow-up Monitor response to antidepressants. » It may take a few weeks for antidepressants to ◆ show effect. Monitor the response carefully before increasing the dose. If symptoms of a ◆ manic episode develop (>> assessment question 2), stop the medication immediately and go to >> PSY module for management of the manic episode. Consider tapering off the medication 9–12 months ◆ after the resolution of symptoms. Reduce the dose gradually over at least 4 weeks. Box DEP 2: Medical management of current depressive episode in a person with bipolar disorder In people with bipolar disorder, never prescribe antidepressants alone without a mood stabilizer, because antidepressants can lead to a manic episode. If the person has a history of manic episode: Consult » a specialist. If » a specialist is not immediately available, prescribe an antidepressant in combination with a mood stabilizer such as carbamazepine or valproate (>> Table DEP 2). Start the medicine at a low dose. Increase slowly over the following weeks. ◆ If possible, avoid carbamazepine and valproate in women who are pregnant or who are ▸ planning pregnancy, because of potential harm to the fetus from the medication. The decision to start mood stabilizers in a pregnant woman should be made in discussion with the woman. The severity and frequency of manic and depressive episodes should be taken into consideration. Consult a specialist for ongoing treatment of bipolar disorder. ◆ Tell » the person and the carers to stop the antidepressant immediately and return for help if symptoms of manic episode develop. Offer » regular follow-up. Schedule and conduct regular follow-up sessions ◆ according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 1 week and ◆ subsequent appointments depending on the course of the disorder. Table DEP 2: Mood stabilizers in bipolar disorder Carbamazepine Valproate Starting dose 200 mg/day 400 mg/day Typical effective dose 400–600 mg/day (max. dose 1400 mg/day) 1000–2000 mg/day(max. dose 2500 mg/day) Dosing schedule Twice daily, oral Twice daily, oral Rare but serious side-effects Severe skin rash (Stevens-Johnson syndrome*, ◆ toxic epidermal necrolysis*) Bone marrow depression* ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Troubling walking ◆ Nausea ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss (re-growth ◆ normally begins within 6 months) Impaired hepatic function ◆

27 PT SD Post-traumatic Stress Disorder PTSD As mentioned in the Acute Stress (ACU) module, it is common for adults, adolescents and children to develop a wide range of psychological reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event*, the person may have developed post-traumatic stress disorder (PTSD). Despite its name, PTSD is not necessarily the only or the main condition that occurs after exposure to potentially traumatic events. Such events can also trigger many of the other mental, neurological and substance use (MNS) conditions described in this guide. Typical presenting complaints of PTSD People with PTSD may be hard to distinguish from those suffering from other problems because they may initially present with non-specific symptoms, such as: sleep problems » (e.g. lack of sleep) irritability, persistent anxious or depressed mood » multiple persistent physical symptoms with no clear » physical cause (e.g. headaches, pounding heart). However, on further questioning they may reveal that they are suffering from characteristic PTSD symptoms. 28 PT SD Assessment Assessment question 1: Has the person experienced a potentially traumatic event more than 1 month ago? 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. Ask if the person has experienced a potentially » traumatic event. This is any threatening or horrific event such as physical or sexual violence (including domestic violence), witnessing of atrocity, destruction of the person’s house, or major accidents or injuries. Consider asking: How have you been affected by the disaster/conflict? ◆ Has your life been in danger? At home or in the community, have you experienced something that was very frightening or horrific or has made you feel very bad? If the person has experienced a potentially traumatic » event, ask when this occurred. Assessment question 2: If a potentially traumatic event occurred more than 1 month ago, does the person have PTSD?8 Assess for: » Re-experiencing symptoms. ◆ These are repeated and unwanted recollections of the event as though it is occurring in the here and now (e.g. through frightening dreams, flashbacks* or intrusive memories* accompanied by intense fear or horror). In children this may involve replaying or drawing ▸ the events repeatedly. Younger children may have frightening dreams without a clear content. Avoidance symptoms. ◆ These involve deliberate avoidance of thoughts, memories, activities or situations that remind the person of the event (e.g. avoiding talking about issues that are reminders of the event, or avoiding going back to places where the event happened). Symptoms related to a ◆ heightened sense of current threat (often called “hyperarousal symptoms”). These involve excessive concern and alertness to danger or reacting strongly to loud noises or unexpected movements (e.g. being “jumpy” or ”on edge”). Considerable ◆ difficulty with daily functioning. If all of the above are present approximately 1 month » after the event, then PTSD is likely. Assessment question 3: Is there a concurrent condition? Assess for and manage any » concurrent physical conditions that may explain the symptoms. Assess for and manage » all other MNS conditions that are covered in this guide. 29 PT SD 1. Educate on PTSD Basic Management Plan Explain that: » Many people recover from PTSD over time without ◆ treatment while others need treatment. People with PTSD repeatedly experience unwanted ◆ recollections of the traumatic event. When this happens, they may experience emotions such as fear and horror similar to the feelings they experienced when the event was actually happening. They may also have frightening dreams. People with PTSD often feel that they are still in ◆ danger and may feel very tense. They are easily startled (“jumpy”) or constantly on the watch for danger. People with PTSD try to avoid any reminders of the ◆ event. Such avoidance may cause problems in their lives. (If applicable), people with PTSD may sometimes have ◆ other physical and mental problems, such as aches and pains in the body, low energy, fatigue, irritability and depressed mood. Advise the person to: » Continue their normal daily routine ◆ as much as possible. Talk to trusted people ◆ about what happened and how they feel, but only when they are ready to do so. Engage in relaxing activities ◆ to reduce anxiety and tension. Avoid using alcohol or drugs ◆ to cope with PTSD symptoms. 2. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » When the person is a victim of severe human rights ◆ violations, discuss with them possible referral to a trusted protection or human rights agency. Strengthen social supports. » Teach stress management. » 3. If trained and supervised therapists are available, consider referring for: Cognitive behavioural therapy with a trauma focus* » Eye movement desensitization and reprocessing » (EMDR)*. 4. In adults, consider antidepressants (selective serotonin reuptake inhibitors or tricyclic antidepressants) when cognitive behavioural therapy, EMDR or stress management do not work or are unavailable Go to the module on moderate-severe depression for » more detailed guidance on prescribing antidepressants (>> DEP). DO NOT offer antidepressants to manage PTSD in » children and adolescents. 5. Follow-up Schedule and conduct regular follow-up sessions » according to the Principles of Management (>> General Principles of Care). Schedule the second appointment within 2–4 weeks and » subsequent appointments depending on the course of the disorder.

PS Y 31 Psychosis PSY Adults and adolescents with psychosis may firmly believe or experience things that are not real. Their beliefs and experiences are generally considered abnormal by their communities. People with psychosis are frequently unaware that they have a mental health condition. They are often unable to function normally in many areas of their lives. During humanitarian emergencies, extreme stress and fear, breakdown of social supports and disruption of health-care services and medication supply can occur. These changes can lead to acute psychosis or can exacerbate existing symptoms of psychosis. During emergencies, people with psychosis are extremely vulnerable to various human rights violations such as neglect, abandonment, homelessness, abuse and social stigma. Typical presenting complaints of psychosis Abnormal behaviour (e.g. strange appearance, self-neglect, incoherent speech, wandering aimlessly, mumbling or laughing to self) Strange beliefs Hearing voices or seeing things that are not there Extreme suspicion Lack of desire to be with or talk with others; lack of motivation to do daily chores and work. PS Y 32 Assessment question 2: Are there acute physical causes of psychotic symptoms that can be managed? Rule out » delirium* from acute physical causes such as head injury, infections (e.g. cerebral malaria, sepsis* or urosepsis*), dehydration and metabolic abnormalities (e.g. hypoglycaemia*, hyponatraemia*). Rule » out medication side-effects (e.g. from certain antimalaria medications). Rule out » alcohol or drug intoxication/withdrawal (>> SUB). Ask about alcohol, sedative or other drug use. ◆ Smell for alcohol. ◆ Assessment question 3: Is this a manic episode? Rule out mania. Assess for: » decreased need for sleep ◆ euphoric, expansive or irritable mood ◆ racing thoughts; being easily distracted ◆ increased activity, feeling of increased energy or rapid ◆ speech impulsive or reckless behaviours such as excessive ◆ gambling or spending, making important decisions without adequate planning unrealistically inflated self-esteem. ◆ Manic episode » is likely if several of these symptoms are present for more than 1 week, and either the symptoms cause considerable difficulty with daily functioning or the person cannot be managed safely at home. Note that while people with psychosis may have » abnormal thoughts, beliefs or speech, this does not mean that everything they say is wrong or imaginary. Careful listening is key to psychosis assessment. More than one visit may be necessary to ensure full assessment. Carers are often a source of helpful information. A » ssess for: Delusions* ◆ (fixed false beliefs or suspicions that are firmly held even when there is evidence to the contrary) Tip: Probe further by asking what the person ▸ means, and listen carefully. Hallucinations* ◆ (hearing, seeing or feeling things that are not there) Do you hear or see things that others cannot? ▸ Disorganized thoughts ◆ that switch between topics without logical connection; speech that is difficult to follow Unusual experiences such as believing that ◆ others place thoughts in one’s mind, that others withdraw thoughts from one’s mind or that one’s thoughts are being broadcast to others Abnormal behaviour ◆ such as odd, eccentric, aimless and agitated activity or maintaining an abnormal body posture or not moving at all Chronic symptoms that involve a loss of normal ◆ functioning, including: lack of energy or motivation to do daily chores ▸ and work apathy and social withdrawal ▸ poor personal care or neglect ▸ lack of emotional experience and expressiveness. ▸ Psychosis » is likely if multiple symptoms are present. Always assess for imminent risk of suicide (>> SUI) and harm to and from others. Assessment Assessment question 1: Does the person have psychosis? PS Y 33 Basic Management Plan 1. For psychosis without acute physical causes A. Pharmacological interventions 2. For psychotic symptoms from acute physical causes (e.g. alcohol withdrawal or delirium) Manage ◆ side-effects. In case of significant acute extrapyramidal ▸ side-effects* such as Parkinsonism (combination of tremors*, muscular rigidity and decreased body movements) or akathisia* (inability to sit still): Reduce the dose of antipsychotic medication. ∙ If ∙ extrapyramidal side effects persist despite reducing the dose, consider short-term use of anticholinergics (e.g. biperiden for 4-8 weeks (>> Table PSY 2). In case of acute ▸ dystonia (acute spasm of muscles, typically of neck, tongue and jaw): Stop ∙ antipsychotic medication temporarily and provide anticholinergics (e.g. biperiden >> Table PSY 2). If these are not available, diazepam may be given to induce muscle relaxation. If possible, consult a specialist about the duration ◆ of treatment and when to discontinue antipsychotic medications. In general, continue the antipsychotic medication ▸ for at least 12 months after the symptoms resolve. Taper down slowly when discontinuing the ▸ medication over several months. Never stop the medication abruptly. ▸ 3. For manic episode Manage the acute cause » . For management of ◆ alcohol withdrawal, see Box 1 in SUB module. In case of acute physical causes ◆ other than alcohol withdrawal, prescribe an oral antipsychotic medication as needed (e.g. haloperidol, initially 0.5 mg per dose up to 2.5–5 mg 3 times a day). Only prescribe antipsychotic medication at a moment when there is a need to control agitation, psychotic symptoms or aggression. Stop the medication as soon as these symptoms resolve. Consider intramuscular treatment only if oral treatment is not feasible. A » manic episode is part of bipolar disorder*. Once the acute mania is managed, the person needs assessment and treatment for bipolar disorder with a mood stabilizer such as valproate or carbamazepine. Consult a specialist for management and/or follow instructions on bipolar disorder in the full mhGAP Intervention Guide. Initiate an » oral antipsychotic medication. Consider intramuscular (i.m.) treatment only if oral treatment is not feasible. Check if the person has used an antipsychotic medication in the past that helped control the symptoms. If yes, resume the medication at the same dose. If the medication is not available, start a new medication. The involvement of a carer or health worker in keeping and giving out the medication will be essential at the start of treatment to ensure safe compliance. Prescribe only ◆ one antipsychotic at a time (e.g. haloperidol >> Table PSY 1). “Start low, go up slow” ◆ : start with the lowest therapeutic dose and increase slowly to achieve the desired effect at the lowest effective dose. Try the medication for an adequate amount of time ◆ at a typical effective dose before considering it ineffective (i.e. for at least 4–6 weeks) (>> Table PSY 1). Use the lowest effective oral dose in women who ▸ are planning pregnancy, are pregnant or are breastfeeding. If agitation cannot be adequately managed by an ◆ antipsychotic alone, give a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. Initiate an » oral antipsychotic medication (>> #1 above under Pharmacological interventions). When » the person is extremely agitated despite antipsychotic treatment, consider adding a dose of benzodiazepine (e.g. diazepam, maximum 5 mg orally) and consult a specialist immediately. PS Y 34 2. Facilitate rehabilitation back into the community Talk with community leaders to increase community » acceptance and tolerance of the person. F » acilitate the inclusion of the person in community- based economic and social activities. Connect with community resources such as community- » based health workers, protection service workers, social workers and disability service workers. Ask for their help in assisting the person to resume appropriate social, educational and occupational activities. 3. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) C. Follow-up Schedule and conduct » regular follow-up sessions according to the Principles of Management (>> General Principles of Care). S » chedule the second visit within 1 week and subsequent visits depending on the course of the condition. Continue the antipsychotic treatment for » at least 12 months after complete resolution of symptoms. If possible, consult a specialist regarding the decision to continue or discontinue the medication. B. Psychosocial interventions For all cases: 1. Offer psychoeducation Key messages to the person and the carer(s): P » sychosis can be treated and the person can recover. S » tress can worsen psychotic symptoms. T » ry to continue regular social, educational and occupational activities as much as possible, even if that may be difficult in the emergency setting. D » o not use alcohol, cannabis or other non-prescribed drugs, because they can make the psychotic symptoms worse. P » eople with psychosis need to take the prescribed medications and return for follow up regularly. R » ecognize if the psychotic symptoms return or worsen. Return to the clinic as management may need to be changed accordingly. Messages to the carer(s): Do » not try to convince the person that his or her beliefs or experiences are false or not real. T » ry to be neutral and supportive even when the person shows unusual or aggressive behaviour. A » void getting into arguments or being hostile towards the person. T » ry to give the person freedom to move about. Avoid restraining the person while ensuring that their basic security and that of others is met. P » sychosis is not caused by witchcraft or spirits. D » o not blame the person or others in the family or accuse them of being the cause of the psychosis. I » f the person has recently given birth, do not leave her alone with the baby, in order to ensure the baby’s safety. Table PSY 1: Antipsychotic medications Medication Haloperidola Chlorpromazine Risperidone Starting dose 2.5 mg daily 50–75 mg daily 2 mg daily Typical effective dose 4–10 mg/day (max. dose 20 mg) 75–300 mg/dayb (max. dose 1000 mg) 4–6 mg/day (max. dose 10 mg) Route Oral/intramuscular Oral Oral Significant side-effects: Extrapyramidal side-effects* +++ + + Sedation (especially in elderly) + +++ + Urinary hesitancy ++ Orthostatic hypotension* + +++ + Neuroleptic malignant syndrome* Rarec Rarec Rarec a Available in the Interagency Emergency Health Kit (WHO, 2011) b Up to 1 g may be necessary in severe cases. c Stop antipsychotic medicine immediately if this syndrome is suspected and keep the person cold and provide sufficient fluid. Table PSY 2: Anticholinergic medications Medication Biperidena Trihexphenidyl Starting dose 1 mg twice daily 1 mg daily Typical effective dose 3–6 mg/day (max. dose 12 mg) 5–15 mg daily (max. dose 20 mg) Route Oral Oral Significant side-effects: Confusion, memory disturbance (especially in elderly) +++ +++ Sedation (especially in elderly) + + Urinary hesitancy ++ ++ a Available in the Interagency Emergency Health Kit (WHO, 2011) 35 EP I Epilepsy/Seizures EPI Epilepsy is the most frequently treated condition of all mental, neurological and substance use (MNS) conditions in humanitarian settings in low- and middle-income countries. Epilepsy affects all age groups including young children. Epilepsy is a chronic neurological condition involving recurrent unprovoked seizures caused by abnormal electrical activity in the brain. There are various types of epilepsy and this module covers only the most prevalent type, convulsive epilepsy. Convulsive epilepsy is characterized by seizures that cause sudden involuntary muscle contractions alternating with muscle relaxation, causing the body and limbs to shake or become rigid. Seizures are often associated with impaired consciousness. A convulsing person may fall and suffer injuries. The supply of antiepileptic medications is often disrupted during humanitarian emergencies. Without continuous access to these medications, people with epilepsy may begin experiencing seizures again, which can be life-threatening. Typical presenting complaints of convulsive epilepsy A history of convulsive movements or seizures. See Box EPI 2 on page 40 for assessment and management of a person who is convulsing or is unconscious following a seizure*. 36 EP I Assessment Ask the person, and carer, if the person has had any of » the following symptoms: convulsive movements lasting longer than 1–2 minutes ◆ loss of or impaired consciousness ◆ stiffness or rigidity of the body or limbs lasting longer ◆ than 1–2 minutes bitten or bruised tongue or bodily injury ◆ loss of bladder or bowel control during the episode. ◆ After the abnormal movements, the person may ◆ demonstrate confusion, drowsiness, sleepiness or abnormal behaviour. The person may also complain of fatigue, headache, or muscle ache. Assessment question 1: Does the person meet the criteria for convulsive seizure? The person meets the criteria for a » convulsive seizure if there are convulsive movements and at least 2 other symptoms from the above list. S » uspect non-convulsive seizures or other medical conditions if only 1 or 2 of the above criteria are present. Consult a specialist if the person has had more than ◆ one non-convulsive seizure. Manage accordingly if other medical conditions are ◆ suspected. Follow up after 3 months to re-assess. ◆ Assessment question 2: In the case of convulsive seizure, is there an acute cause? Check for signs and symptoms of » neuroinfection: fever ◆ headache ◆ meningeal irritation* (e.g. stiff neck). ◆ C » heck for other possible causes of convulsions: head injury ◆ metabolic abnormality* (e.g. hypoglycaemia*, ◆ hyponatraemia*) alcohol or drug intoxication or withdrawal ◆ (>> Box SUB 1 on page 48). If » there is an identifiable acute cause of convulsive seizure, treat the cause. Maintenance treatment with antiepileptic ◆ medications is not required in these cases. Refer to a hospital immediately » if neuroinfection*, head injury or metabolic abnormality is suspected. Suspect neuroinfection in a ◆ child (aged 6 months to 6 years) with a fever if any of the following criteria for complex febrile seizures is present: focal seizure – seizure starts in one part of the body ▸ prolonged seizure – seizure lasts more than ▸ 15 minutes repetitive seizure – more than 1 seizure during ▸ the current illness. If none of the above 3 criteria are present in a febrile ◆ child, suspect simple febrile seizure. Manage the fever and look for its cause according to local IMCI guidelines. Observe the child for 24 hours. Follow » up in 3 months to re-assess. Assessment question 3: In the case of convulsive seizure without an identified acute cause, is this epilepsy? It is considered » epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2 different days in the last 12 months. If there was only 1 convulsive seizure in the last 12 » months without an acute cause, then antiepileptic treatment is not required. Follow up in 3 months. 37 EP I Basic Management Plan 1. Educate the person and carers about epilepsy Explain: » What epilepsy is and ◆ what causes it: Epilepsy is a chronic condition, but with medication ▸ three out of every four people can be seizure-free. Epilepsy involves recurrent seizures. ▸ A seizure is a problem related to abnormal electrical activity in the brain. Epilepsy is not caused by witchcraft or spirits. ▸ Epilepsy is not contagious. Saliva does not transmit ▸ epilepsy. What the relevant ◆ lifestyle issues are: People with epilepsy can lead normal lives: ▸ They can marry and have healthy children. ∙ They can work productively and safely at most jobs. ∙ Children with epilepsy can go to school. ∙ People with epilepsy should ▸ avoid: jobs that require working near heavy machinery or fire ∙ cooking over open fires ∙ swimming alone ∙ alcohol and recreational drugs ∙ looking at flashing lights. ∙ changing sleep patterns (e.g. sleeping much less ∙ than usual). What to do at home ◆ when seizures occur (message to carers): If a seizure starts while the person is standing ▸ or sitting, help to prevent a fall injury by gently assisting them to sit or lie on the ground. Make sure that the person is breathing properly. ▸ Loosen the clothes around the neck. Place the person in the recovery position ▸ (see Figures A–D below). Figures A–D: The recovery position Ask the person and the carers to keep a simple seizure diary (see » Figure EPI GPC 1). Kneel on the floor on one side of the person. A. Place the arm closest to you at a right angle to their body with the person’s hand upwards towards the head (see Figure A above). Place the other hand under the side of the person’s B. head, so that the back of the hand is touching the cheek (see Figure B above). Bend the knee furthest from you to a right angle. C. Roll the person carefully onto his or her side by pulling on the bent knee (see Figure C above). The person’s top arm should be supporting the head D. and the bottom arm will stop the person from rolling too far (see Figure D above). Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that nothing is blocking the airway. This manoeuvre moves the tongue out of the airway and helps the person breathe better and prevents choking from secretions and vomit. Do not try to restrain or hold the person to the floor. ▸ Do not put anything in the person’s mouth. ▸ Move any hard or sharp objects away from the ▸ person to prevent injury. Stay with the person until the seizure stops and the ▸ person regains consciousness. A C B D 38 EP I 2. Initiate or resume antiepileptic drugs Check if the person has ever used an antiepileptic » medication that controlled the seizures. If yes, then resume the same medication at the same dose. If » the medication is not available, start a new medication. Choose » only one antiepileptic drug (see Table EPI 1). Consider potential side-effects, drug-disease ◆ interactions* or drug-drug interactions*. Consult the National or WHO Formulary, as necessary. Start with the ◆ lowest dose and increase gradually until complete seizure control is obtained. Explain » to the person and carers: Medication dosing schedule ◆ (>> Table EPI 1) Potential side-effects ◆ (>> Table EPI 1). Most side-effects are mild and will resolve over time. If severe side-effects occur, the person should immediately stop the medication and seek medical help. Importance of medication ◆ adherence. Missed doses or abrupt discontinuation can cause seizures to recur. The medications should be taken at the same time each day. Time for the medication to start working. It usually ◆ takes a few weeks before the effect becomes clear. Duration of treatment. Continue the medication until ◆ the person has not had a seizure for at least 2 years. Importance of regular follow-up. ◆ Table EPI 1: Antiepileptic medications Phenobarbitala Carbamazepine Phenytoin Valproate Starting dose in children 2–3 mg/kg/day 5 mg/kg/day 3–4 mg/kg/day 15–20 mg/kg/day Typical effective dose in children 2–6 mg/kg/day 10–30 mg/kg/day 3–8 mg/kg/day (max. dose 300 mg/day) 15–30 mg/kg/day Starting dose in adults 60 mg/day 200–400 mg/day 150–200 mg/day 400 mg/day Typical effective dose in adults 60–180 mg/day 400–1400 mg/day 200–400 mg/day 400–2000 mg/day Dosing schedule Once daily at bedtime Twice daily In children, give twice daily; in adults, it can be given once daily Usually 2 or 3 times daily Rare but serious side-effects Severe skin rash (Stevens- ◆ Johnson syndrome*) Bone marrow ◆ depression* Liver failure ◆ Severe skin rash ◆ (Stevens-Johnson syndrome*, toxic epidermal necrolysis*) Bone marrow ◆ depression* Anaemia and other ◆ haematological abnormalities Hypersensitivity ◆ reactions including severe skin rash (Stevens-Johnson syndrome*) Hepatitis ◆ Drowsiness ◆ Confusion ◆ Common side-effects Drowsiness ◆ Hyperactivity in children ◆ Drowsiness ◆ Trouble walking ◆ Nausea ◆ Nausea, vomiting, ◆ constipation Tremor ◆ Drowsiness ◆ Ataxia and slurred ◆ speech Motor twitching ◆ Mental confusion ◆ Lethargy ◆ Sedation ◆ Tremor ◆ Nausea, diarrhoea ◆ Weight gain ◆ Transient hair loss ◆ (regrowth normally begins within 6 months) Impaired hepatic ◆ function Precautions Avoid phenobarbital in ◆ children with intellectual disability or behavioural problems Avoid valproate ◆ in pregnant women a Available in the Interagency Emergency Health Kit (WHO, 2011) 39 EP I E » nsure regular follow-up: For the first 3 months or until seizures are controlled, ◆ schedule follow-up appointments at least once a month. Meet every 3 months if seizures are controlled. ◆ Refer to ◆ Principles of Management (>> General Principles of Care) for more detailed advice on follow-up. At » each follow-up: Monitor for seizure control: ◆ Refer to the ▸ seizure diary to see how well seizures are controlled. Maintain or adjust the antiepileptic medication ◆ according to how well the seizures are controlled. If seizures are still not controlled at the maximum ▸ therapeutic dose of one medication or the side- effects have become intolerable, change to another medication. Gradually increase the dose until seizures are controlled. If seizures are very infrequent and a further ▸ increase in the dose may produce severe side- effects, then the current dose may be acceptable. Consult a specialist if 2 medications were tried ▸ one after another and neither achieved adequate seizure control. Avoid treatment with more than one antiepileptic medication at a time. Consider ◆ stopping the antiepileptic medication if no seizure has occurred in the last 2 years. When stopping the medication, the dose should be ▸ tapered down slowly over several months to avoid seizures from medication withdrawal. Involve carers in monitoring for seizure control. ◆ Review lifestyle issues and provide further ◆ psychoeducation/support to the person and the carers (>> Basic management plan step 1 described above). Box EPI 1: Special management considerations for women with epilepsy If » the woman is of childbearing age: Give folate 5 mg/day to prevent possible birth ◆ defects if she becomes pregnant. If » she is pregnant: Consult with a specialist for management. ◆ Advise more frequent antenatal visits and delivery in ◆ a hospital. At delivery, give 1 mg ◆ vitamin K intramuscularly (i.m.) to the newborn. The decision to start an antiepileptic medication in a » pregnant woman should be made together with the woman. The severity and frequency of the seizures as well as the potential harm to the fetus from either the seizures or the medication should be considered. If the decision is made to start medication, then either phenobarbital or carbamazepine can be used. Valproate and polytherapy* should be avoided. Carbamazepine » can be used by women who are breastfeeding. 3. Follow-up Figure EPI 1: Example seizure diary When the seizure occurred Description of seizure (including body parts affected and duration of seizure) Medications that were taken Date Time Yesterday Today 40 EP I Box EPI 2: Assessment and management of a person who is convulsing or is unconscious following a seizure Assessment and management of acute seizures should proceed simultaneously. Assessment of seizures» Stay calm.◆ Most seizures will stop after a few minutes. Check ◆ airway, breathing and circulation, including blood pressure, respiratory rate and temperature. Check for ◆ signs of head or spinal injury (e.g. dilated pupils may be a sign of serious head injury). Check for ◆ stiff neck or fever (signs of meningitis). Ask» the carer: When did this seizure start?◆ Is there a past history of seizures?◆ Is there is a history of head or neck injury?◆ Are there other medical problems?◆ Did the person take any medication, poison, alcohol◆ or drugs? If ◆ female: Is she in the second half of pregnancy or first week after delivery? Refer» urgently to a hospital: If there is any sign of ◆ major injury, shock* or breathing problem If the person may have had a ◆ serious head or neck injury: Do not move the person’s neck.▸ Log-roll* the person when transferring them.▸ If the person is a woman in the ◆ second half of pregnancy or less than 1 week after delivery If ◆ neuroinfection is suspected If it has been◆ more than 5 minutes since the seizure started. » Management of seizures ◆ Put the person on their side in the recovery position (see Basic management plan and Figures A–D above). ◆ If the seizure does not spontaneously stop after 1–2 minutes, insert an intravenous (i.v.) line as quickly as possible and give glucose and benzodiazepines slowly (30 drops/minute). ▸ If an i.v. line is difficult to establish, give the benzodiazepines through the rectum. ▸ Caution: benzodiazepines can slow down breathing. Give oxygen if available and monitor the person’s respiratory status frequently. ▸ Child glucose dose: 2–5 ml/kg of 10% glucose ▸ Child benzodiazepines dose: ∙ diazepam rectally 0.2–0.5 mg/kg or ∙ diazepam i.v. 0.1–0.3 mg/kg or ∙ lorazepam i.v. 0.1 mg/kg. ▸ Adult glucose dose: 25-50 ml of 50% glucose ▸ Adult benzodiazepines dose: ∙ diazepam rectally 10–20 mg or ∙ diazepam i.v. 10–20 mg slowly or ∙ lorazepam i.v. 4 mg. ▸Do not give benzodiazepines intramuscularly (i.m.). ◆ Give the second dose of benzodiazepines if the seizure continues for 5–10 minutes after the first dose. ◆ Use the same dose as the first dose. ◆ Do not give more than 2 doses of benzodiazepines. If the person needs more than 2 doses, they should be sent to a hospital. ◆ Suspect status epilepticus if: ▸ Seizures occur frequently and the person does not recover in between episodes, or ▸ Seizures are not responsive to 2 doses of benzodiazepines, or ▸ Seizures last for more than 5 minutes. » Refer urgently to a hospital: ◆ If status epilepticus is suspected (see above) ◆ If the person does not respond to the first 2 doses of benzodiazepines ◆ If the person is having breathing problems after receiving benzodiazepines. 41 ID Intellectual Disability ID Intellectual disability9 is characterized by limitations across multiple areas of expected intellectual development (i.e. cognitive*, language, motor and social skills) that are not reversible. The limitations have existed from birth or started during childhood. Intellectual disability interferes with learning, daily functioning and adaptation to a new environment. People with intellectual disability often have substantial care needs. They often experience challenges in accessing health care and education. They are extremely vulnerable to abuse, neglect and exposure to hazardous situations in chaotic emergency environments. For example, people with intellectual disability are more likely to walk into dangerous areas unknowingly. Moreover, they can be perceived as burdensome by their families and communities and may be abandoned during displacement. Therefore, people with intellectual disability require extra attention during humanitarian emergencies. This module covers moderate, severe and profound intellectual disability in children, adolescents and adults. Typical presenting complaints In » infants: poor feeding, failure to thrive, poor motor tone, delay in meeting expected developmental milestones for appropriate age and stage such as smiling, sitting, standing. In » children: delay in meeting expected developmental milestones for appropriate age such as walking, toilet training, talking, reading and writing. In » adults: reduced ability to live independently or look after oneself and/or children. In » all ages: difficulty carrying out daily activities considered normal for the person’s age; difficulty understanding instructions; difficulty meeting demands of daily life. 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. 42 ID Assessment question 1: Does the person have intellectual disability? Assessment Review » the person’s skills and functioning: For ◆ young children and toddlers, assess whether the child has fully reached age-appropriate milestones across all developmental areas (>> Box ID 1 with warning signs). Suggested ◆ questions to carers of children: Is your child behaving like others of the same age? ▸ What kinds of things can your child do alone ▸ (sitting, walking, eating, dressing or toileting)? How does your child communicate with you? ▸ Does the child smile at you? Does the child react to his/her name? How does the child talk to you? Is the child able to ask for what he/she wants? How does your child play? Is your child able to play ▸ well with other children of the same age? For ◆ older children and adolescents, ask whether they go to school and, if so, how they are managing schoolwork (learning, reading and writing) and everyday household activities. Are you going to school? How are you doing in ▸ school? Are you able to finish your schoolwork? Do you often have difficulties in school because you cannot understand or follow instructions? For ◆ adults, ask whether they work and, if so, how they are managing their work and other daily activities. Do you work? What kind of work do you do? ▸ Do you often get into trouble at work because you cannot understand or follow instructions? For ◆ older children, adolescents and adults, ask how much help the person is currently receiving to do daily activities (e.g. at home, school, work). If » there is delay in reaching expected developmental milestones, rule out treatable or reversible conditions that can mimic intellectual disability. Rule ◆ out visual impairment: For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child can follow a moving object with ∙ their eyes if the child can recognize familiar people ∙ if the child can grab an object with their hands. ∙ If any of the answers is ▸ No, inform the carer that the child may have impaired vision and consult a specialist, if available. Rule out hearing impairment: ◆ For a child >6 months, ask the carer if the child can ▸ do the following, while directly observing the child yourself: if the child turns his/her head to see who is ∙ speaking from behind if the child reacts to loud noises ∙ if the child makes various vocal sounds (tata, ∙ dada, baba). If any of the answers is ▸ No, inform the carer that the child may have impaired hearing and consult a specialist, if available. Rule ◆ out problems in the environment: Moderate-severe depressive disorder in the mother ▸ or main carer (>> DEP) Lack of stimulation (stimulation is essential for ▸ brain development in young children). Who regularly interacts and plays with the child? ∙ How do you/they play with your child? ∙ How often? How do you/they communicate with your child? ∙ How often? Rule ◆ out malnutrition and other nutritional or hormonal deficiencies including iodine deficiency* and hypothyroidism*. Rule ◆ out epilepsy (>> EPI), which can mimic or occur together with intellectual disability. Manage » the identified treatable problems and follow up to reassess whether the person has intellectual disability. For confirmed cases of hearing and visual ◆ impairments, provide or advocate for necessary aids (glasses, hearing aid). Manage depressive disorder in the carer, if applicable. ◆ Teach the carer how to provide a more stimulating ◆ environment for young children. See Counsel the Family for Care for Development: Counselling Cards (UNICEF and WHO, 2012). Refer the person to Early Childhood Development ◆ (ECD) programmes, if appropriate. Intellectual » disability is likely if a) there is a significant delay in reaching expected developmental milestones and difficulty meeting demands of daily life and b) treatable or reversible conditions have been ruled out or addressed. Assessment question 2: Are there associated behavioural problems? Not listening to carers » Temper » tantrums. Aggression and self-harming behaviour when upset Eating non-organic materials » Reckless » sexual or other problematic behaviour. 43 ID Basic Management Plan Explain the disability » to the person and their carers. People with intellectual disability should not be blamed for the disability. The aim is for the carers to have realistic expectations and to be kind and supportive. Provide » parenting skills training. The aim should be to improve positive interactions between parent/carer and child. Teach the carers skills that can help reduce behaviour problems. Carers should understand the importance of training ◆ the person to perform self-care and hygiene (e.g. toilet training, brushing teeth). Carers should have very good knowledge of the ◆ person. Carers should know what stresses the person and what makes them happy, what causes behaviour problems and what prevents them, what the person’s strengths and weaknesses are and how the person learns best. Carers should keep the person’s daily activities such ◆ as eating, playing, learning, working and sleeping as regular as possible. 1. Offer psychoeducation Carers should reward the person ◆ when the behaviour is good and withhold rewards when the behaviour is problematic. Use a balanced discipline: Give clear, simple and short instructions on what ▸ the person should do rather than what the person should not do. Break complex activities into smaller steps so that the person can learn and be rewarded one step at a time (e.g. learning to put trousers on before buttoning them up). When the person does something good, offer a ▸ reward. Distract the person from the things they should not do. However, such distraction should not be pleasurable and rewarding for the person. DO NOT use threats or physical punishments when ▸ the behaviour is problematic. Educate » the carers that the person is more vulnerable to physical and sexual abuse in general, requiring extra attention and protection. E » ducate carers to avoid institutionalization. Assess the availability of community-based protection » (e.g. informal groups, local NGOs, governmental agencies or international agencies) and ask for relevant support for the person. 2. Promote community-based protection 3. Advocate for inclusion in community activities If the person is a child, keep them in normal schools » as much as possible. Liaise with the child’s school to explore possibilities ◆ of adapting the learning environment to the child. Simple tips are available in Inclusive Education of Children At Risk (INEE). Encourage participation in enjoyable social activities in » the community. Assess » availability of community-based rehabilitation (CBR*) programmes and advocate to have the person with intellectual disability included in such programmes. 4. Care for the carers according to the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 5. If possible, refer to a specialist for further assessment and management of possible concurrent developmental conditions Irreversible motor impairment or cerebral palsy* » Birth defects, genetic abnormalities or syndromes » (e.g. Down syndrome*). 6. Follow-up Schedule and conduct follow-up sessions according » to the Principles of Management (>> General Principles of Care). 44 ID Box ID 1: Developmental milestones: warning signs to watch for By the age of 1 MONTH Poor suckling at the breast or refusing to suckle ◆ Little movement of arms and legs ◆ Little or no reaction to loud sounds or bright lights ◆ Crying for long periods for no apparent reason ◆ Vomiting and diarrhoea, which can lead to dehydration ◆ By the age of 6 MONTHS Stiffness or difficulty moving limbs ◆ Constant moving of the head (this might indicate an ear infection, which could ◆ lead to deafness if not treated) Little or no response to sounds, familiar faces or the breast ◆ Refusing the breast or other foods ◆ By the age of 12 MONTHS Does not make sounds in response to others ◆ Does not look at objects that move ◆ Listlessness and lack of response to the caregiver ◆ Lack of appetite or refusal of food ◆ By the age of 2 YEARS Lack of response to others ◆ Difficulty keeping balance while walking ◆ Injuries and unexplained changes in behaviour (especially if the child has been ◆ cared for by others) Lack of appetite ◆ By the age of 3 YEARS Loss of interest in playing ◆ Frequent falling ◆ Difficulty manipulating small objects ◆ Failure to understand simple messages ◆ Inability to speak using several words ◆ Little or no interest in food ◆ By the age of 5 YEARS Fear, anger or violence when playing with other children, which could be signs ◆ of emotional problems or abuse By the age of 8 YEARS Difficulties making and keeping friends and participating in group activities ◆ Avoiding a task or challenge without trying, or showing signs of helplessness ◆ Trouble communicating needs, thoughts and emotions ◆ Trouble focusing on tasks, understanding and completing schoolwork ◆ Excessive aggression or shyness with friends and family ◆ Source: UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and World Bank (2010) 45 SU B Harmful Use of Alcohol and Drugs SUB Use of alcohol or drugs (e.g. opiates* (e.g. heroin), cannabis*, amphetamines*, khat*, diverse prescribed medications such as benzodiazepines* and tramadol*) can lead to various problems. These include withdrawal (physical and mental symptoms that occur upon cessation or significant reduction of use), dependence* and harmful use (damage to physical or mental health and/or general well-being). Use of alcohol or drugs is harmful when it leads to physical or mental disorders, risky health behaviours, family/relationship problems, sexual and physical violence, accidents, child abuse and neglect, financial difficulties and other protection issues. The prevalence of harmful alcohol or drug use may increase during humanitarian emergencies as adults and adolescents may try to cope with stress, loss or pain by self-medicating*. Acute emergencies can disrupt alcohol or drug supply, leading to unexpected life- threatening withdrawal symptoms in individuals who were using substances over a prolonged period of time at relatively high doses. This is particularly true for alcohol. This module focuses on harmful use of alcohol or drugs and includes a box on life-threatening alcohol withdrawal (>> Box SUB 1). For other aspects of alcohol or drug use, see alcohol or drug use modules of the full mhGAP Intervention Guide. Typical presenting complaints Appearing » to be under the influence of alcohol or drugs (e.g. smelling of alcohol, looking intoxicated, being agitated, fidgeting, having low energy, slurred speech, unkempt appearance, dilated/constricted pupils*) Recent injury » Signs of intravenous (i.v.) drug use » (injection marks, skin infection) Requests for sleeping tablets or painkillers. » See Box SUB 1 on page 48 for assessment and management of life-threatening alcohol withdrawal. 46 SU B Assessment Assessment question 1: Is there harm to physical or mental health and/or general well-being from alcohol or drug use? Explore the use of alcohol or drugs, without sounding » judgemental. Ask » : Amount ◆ and pattern of use Do you drink alcohol? If so, in what form? ▸ How many drinks per day/week? Do you use prescribed sleeping tablets/anxiety ▸ pills/painkillers? What kind? How many per day/ week? Do you use illegal drugs? What kind? ▸ How do you take them – by mouth, injection, snorting? How much/how often per day/week? Triggers ◆ to alcohol or drug use What makes you want to take alcohol or drugs? ▸ Harm ◆ to self or others Medical problems or injuries ▸ as a result of alcohol or drug use Have you experienced health problems since you ∙ started drinking alcohol or using drugs? Have you ever been injured while you were ∙ under the influence of alcohol or drugs? Continued use of alcohol or drugs despite advice ▸ to stop When the person was pregnant or breastfeeding ∙ When the person was told there is a problem ∙ with their stomach or liver because of drinking or drug use When the person was on medications that have ∙ harmful interactions with alcohol or drugs, such as sedatives, analgesics or tuberculosis medications Social problems ▸ as a result of alcohol or drug use: Financial or legal problems ∙ Have you ever been in trouble with money or ∙ broken the law because of alcohol or drug use? Occupational problems ∙ Have you ever lost a job or done badly at work ∙ because of your alcohol or drug use? Difficulty caring for children or other dependants ∙ Have you ever found it hard to take care of your ∙ child/family because of alcohol or drug use? Violence towards others ∙ Have you ever hurt someone while taking ∙ alcohol or drugs? Relationship/marital problems ∙ Has your alcohol or drug use ever caused ∙ a problem with your partner? Perform » a quick general physical examination to look for the signs of chronic alcohol or drug use Gastrointestinal bleeding ◆ abdominal pain ▸ blood in vomit ▸ blood in stool or black stool ▸ Liver disease ◆ Severe: jaundice, ascites*, enlarged and hardened ▸ liver and spleen, hepatic encephalopathy* Malnutrition, severe weight loss ◆ Evidence of infections associated with drug use ◆ (e.g. HIV, hepatitis B or C, injection site skin infections or tuberculosis). Assess » for both harmful alcohol and drug use in the same person as they often occur together. 47 SU B Basic Management Plan 1. Manage the harmful effects of alcohol or drug use Provide necessary » medical care for physical consequences of harmful alcohol or drug use. Manage » any concurrent mental conditions, such as moderate-severe depressive disorder, PTSD and psychosis (>> DEP, PTSD, PSY). Address » urgent social consequences (e.g. liaise with protection services in case of abuse, such as gender- based violence). 2. Assess the person’s motivation to stop or reduce the use of alcohol or drugs Assess whether the person sees alcohol or drug use as » a problem and if the person is ready to do something about it. Do you think you may have a problem with alcohol ◆ or drugs? Have you thought about stopping or reducing your ◆ alcohol or drug use? Have you tried stopping or reducing alcohol or drug ◆ use in the past? 3. Motivate the person to either stop or reduce the use of alcohol or drugs Initiate a » brief motivational conversation about harmful use: Ask about the ◆ perceived benefits and harms of alcohol or drug use. Do not be judgemental, but try to understand what motivates the person to use alcohol or drugs. What kind of pleasure do you get when taking ▸ alcohol or drugs? Do you see any negative aspects of taking alcohol ▸ or drugs? Did you ever regret using alcohol or drugs? ▸ Challenge ◆ any exaggerated sense of benefit from alcohol or drug use. For example, if the person uses alcohol or drugs to try to forget life problems, say: Is ▸ forgetting the problem really a good thing? Does that make the problem go away? Highlight ◆ some of the negative aspects of alcohol and drug use that may have been underestimated by the person. How much money do you spend buying alcohol ▸ or drugs? Per week? Per month? Per year? What else could you be doing with that money? Provide ◆ additional information on the harmful effects of alcohol and drugs, both short-term and long-term. Alcohol or drugs may result in serious medical ▸ and mental health problems, including injuries and addiction. Acknowledge ◆ that stopping alcohol or drug use is difficult. Let the person know you are willing to support them. Encourage people to decide for themselves if it is a good idea to stop alcohol or drugs. If ◆ the person is not ready to stop or reduce alcohol or drugs, respect the decision. Ask the person to come back another time to talk further. Repeat » the brief motivational conversations described above over several sessions. 4. Discuss various ways to reduce or stop harmful use Discuss the following strategies: » Do not store alcohol or drugs at home. ◆ Do not go near places where people may use alcohol ◆ or drugs. Ask for support from carers and friends. ◆ Ask carers to accompany the person to follow-up visits. ◆ Encourage social activities without alcohol or drugs. ◆ Consider referral to a self-help group for alcohol » or drug use, if available. If » the person agrees to stop using alcohol or drugs, then inform them of the possibility of developing transient withdrawal symptoms (i.e. <1 week). Describe the symptoms (e.g. anxiety and agitation after withdrawal from opiates, benzodiazepines and alcohol). Advise the person to return to the clinic if there are severe symptoms. 5. Offer psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. Teach stress management. » 6. Offer regular follow-up Continue to offer support, discuss and work together » with the person and the carers about reducing or stopping alcohol or drug use. Schedule and conduct regular follow-up sessions (>> Principles of Management in General Principles of Care). 48 SU B Box SUB 1 Assessment and management of life-threatening alcohol withdrawal Typical presenting complaints of person with life-threatening alcohol withdrawal A » gitation, severe anxiety Confusion » or hallucinations* (seeing, hearing or feeling things that are not there) Convulsions/seizures » Increased » blood pressure (e.g. >180/100 mm Hg) and/or heart rate (e.g >100 bpm). Assessment of life-threatening alcohol withdrawal Assessment question 1: Is this alcohol withdrawal? Rule out and manage other causes » that can explain the symptoms, including: Malaria, HIV/AIDS, other infections, head injury, ◆ metabolic abnormality* (e.g. hypoglycemia*, hyponatraemia*), hepatic encephalopathy, hyperthyroidism*, stroke, drug use (e.g. amphetamines), known history of psychosis and known history of epilepsy. If » the above causes are ruled out, take an alcohol history by asking the person and carers: Does the person drink alcohol? ◆ When was the last drink? ◆ How much does the person usually drink? ◆ Alcohol » withdrawal is likely if the symptoms develop after the cessation of regular/heavy alcohol use. This happens typically 1–2 days after the last drink. If the person has seizures or hallucinations and if ◆ alcohol withdrawal is not suspected, then assess for epilepsy (>> EPI) or psychosis (>> PSY). Assessment question 2: If the person has alcohol withdrawal, is this life-threatening alcohol withdrawal? Assess for » life-threatening features: Convulsions/seizures (typically within 48 hours) ◆ Features of delirium* (typically within 96 hours) ◆ acute confusion, disorientation ▸ hallucinations. ▸ Assess » whether the person is at high risk of developing life-threatening features (convulsions or delirium) in the next 1–2 days: Previous life-threatening features (convulsions or ◆ delirium) or Current and severe withdrawal symptoms: ◆ severe agitation, severe irritability, severe anxiety ▸ excessive sweating, tremor of hands ▸ increased blood pressure (e.g. >180/100 mm Hg) ▸ and/or heart rate (e.g. >100 bpm). Emergency management plan for life-threatening alcohol withdrawal 1. Treat alcohol withdrawal immediately with diazepam (>> Table SUB 1) T » he dose of diazepam treatment depends on the person’s tolerance* for diazepam, the severity of the withdrawal symptoms and the presence of concurrent physical disorders. Adjust the dose to the observed effect. The right dose ◆ is the one that gives slight sedation. Too high a dose can cause over-sedation and depress ▸ respiration. Monitor the person’s respiratory rate and level of sedation (e.g. sleepiness) frequently. Too low a dose risks seizures/delirium. ▸ Monitor » the withdrawal symptoms frequently (every 3–4 hours). Continue to use diazepam until symptoms resolve (typically 3–4 days but no longer than 7 days). In » the case of a withdrawal seizure, DO NOT use antiepileptic drugs. Continue using diazepam. S » ymptoms of delirium such as confusion, agitation or hallucinations can persist for several weeks after other alcohol withdrawal symptoms have resolved. In this case, consider using antipsychotics such as haloperidol 2.5–5 mg orally up to 3 times daily until confusion, agitation or hallucinations improve. In some cases it may take several weeks for hallucinations and confusion to resolve. Do not oversedate. If possible, provide a quiet, non-stimulating and well-lit » environment. Try to provide some light even at night to prevent falls if the person decides to get up in the middle of the night. Consider putting the person on a mattress on the floor to prevent injury. If possible, ask a carer to stay with the person and monitor. Avoid restraints if at all possible. 2. Address malnutrition G » ive vitamin B1 (thiamine) 100 mg/day orally for 5 days. A » ssess for and address malnourishment. 3. Maintain hydration S » tart i.v. hydration if possible. E » ncourage oral fluid intake (at least 2–3 litres/day). 4. When the life-threatening withdrawal is over, proceed to assessment and management of harmful alcohol or drug use (see main text of this module) If delirium due to alcohol withdrawal is suspected, initiate the emergency management plan for life- threatening alcohol withdrawal (see below) and arrange accompanied transfer to the nearest hospital. Table SUB 1: Diazepam for life-threatening alcohol withdrawal Diazepama Initial dose 10–20 mg up to 4 times/day for 3–7 days Subsequent dose Gradually decrease the dose and/or frequency as soon as the symptoms improve.Monitor frequently, as people respond differently to this medication Route Oral Severe side-effects (rare) Respiratory depression*, severely impaired consciousnessCaution: monitor respiratory rate and level of sedation frequently Common side-effects Drowsiness, amnesia, altered consciousness, muscle weaknessCaution: do not give another dose if the person is drowsy Precautions in special groups Use one quarter to half of the suggested dose in older peopleDo not use in people with respiratory problems a Available in the Interagency Emergency Health Kit (WHO, 2011) 49 SU I Suicide SUI Mental disorder, acute emotional distress and hopelessness are common in humanitarian settings. Such problems may lead to suicide* or acts of self-harm*. Some health-care workers mistakenly fear that asking about suicide will provoke the person to attempt suicide. On the contrary, talking about suicide often reduces the person’s anxiety around suicidal thoughts, helps the person feel understood and opens opportunities to discuss the problem further. Adults and adolescents with any of the mental, neurological or substance use (MNS) conditions covered in this guide are at risk of suicide or self-harm. Typical presenting complaints of a person at risk of suicide or self-harm Feeling extremely upset or distressed Profound hopelessness or sadness Past attempts of self-harm (e.g. acute pesticide intoxication, medication overdose, self-inflicted wounds). 50 SU I Box SUI 1: How to talk about suicide or self-harm 1. Create a safe and private atmosphere for the person to share thoughts. Assessment question 1: Has the person recently attempted suicide or self-harm? Do not judge the person for being suicidal. » Offer to talk with the person alone or with other » people of their choice. 2. Use a series of questions where any answer naturally leads to another question. For example: [Start with the present] » How do you feel? [ » Acknowledge the person’s feelings] You look sad/ upset. I want to ask you a few questions about it. How » do you see your future? What are your hopes for the future? S » ome people with similar problems have told me that they felt life was not worth living. Do you go to sleep wishing that you might not wake up in the morning? Do you think about hurting yourself? » Have you made any plans to end your life? » If so, how are you planning to do it? » Do you have the means to end your life? » Have you considered when to do it? » Have you ever attempted suicide? » 3. If the person has expressed suicidal ideas: Maintain a calm and supportive attitude » Do not make false promises. » Assessment Assess for: » Poisoning ◆ , alcohol/drug intoxication, medication overdose or other self-harm Signs requiring urgent medical treatment ◆ Bleeding from self-inflicted wound ▸ Loss of consciousness ▸ Extreme lethargy. ▸ Assessment question 2: Is there an imminent risk of suicide or self-harm? Ask the person and/or carers about: » Thoughts or plans of suicide ◆ (currently or in past month) Acts of self-harm in the past year ◆ Access to means of suicide (e.g. pesticides, rope, ◆ weapons, knives, prescribed medications and drugs). Look for: » Severely emotional distress or hopelessness ◆ Violent behaviour or extreme agitation ◆ Withdrawal or unwillingness to communicate. ◆ The person is considered at » imminent risk of suicide or self-harm if either of the following is present: Current thoughts ◆ , plans or acts of suicide History of thoughts or plans ◆ of self-harm in the past month or acts of self-harm in the past year in a person who is now extremely agitated, violent, distressed or uncommunicative. Assessment question 3: Are there concurrent conditions associated with suicide or self-harm? Assess and manage possible concurrent conditions: » Chronic pain or disability (e.g. due to recent injuries ◆ incurred during the humanitarian emergency) Moderate-severe depressive disorder ◆ (>> DEP) Psychosis ◆ (>> PSY) Harmful alcohol or drug use ◆ (>> SUB) Post-traumatic stress disorder ◆ (>> PTSD) Acute emotional distress ◆ (>> ACU, GRI, OTH). 51 SU I 1. If the person has attempted suicide, provide the necessary medical care, monitoring and psychosocial support Provide medical care » : Treat those who have inflicted self-harm with the ◆ same care, respect and privacy given to others. Do not punish them. Treat the injury or poisoning. ◆ For acute pesticide intoxication, see ▸ Clinical Management of Acute Pesticide Intoxication (WHO, 2008). In the case of a prescribed medication overdose ◆ where medication is still required, choose the least harmful alternative medication. If possible, prescribe the new medication for short periods of time only (e.g. a few days to 1 week at a time) to prevent another overdose. Basic Management Plan Monitor » the person continuously while they are still at imminent risk of suicide (see below for guidance). Offer psychosocial support (see below for guidance). » C » onsult a mental health specialist if available. 2. If the person is at imminent risk of suicide or self-harm, monitor and provide psychosocial support Monitor the person » : Create a safe and supportive environment for the ◆ person. Remove all possible means of self-harm/ suicide and, if possible, offer a separate, quiet room. However, do not leave the person alone. Have carers or staff stay with the person at all times. DO NOT routinely admit people to general medicine ◆ wards to prevent acts of suicide. Hospital staff may not be able to monitor a suicidal person sufficiently. However, if admission to a general ward for the medical consequences of self-harm is required, monitor the person closely to prevent subsequent acts of self-harm in the hospital. Regardless of the location, ensure that the person ◆ is monitored 24 hours a day until they are no longer at imminent risk of suicide. Offer psychosocial support » : DO NOT start by offering potential solutions to the ◆ person’s problems. Instead, try to instil hope. For example: Many people who have been in similar situations ▸ – feeling hopeless, wishing they were dead – have then discovered that there is hope, and their feelings have improved with time. Help the person to identify reasons to stay alive. ◆ Search together for solutions to the problems. ◆ Mobilize carers, friends, other trusted individuals ◆ and community resources to monitor and support the person if they are at imminent risk of suicide. Explain to them about the need for 24-hour-per-day monitoring. Ensure that they come up with a concrete and feasible plan (e.g. who is monitoring the person at what time of the day). Offer additional psychosocial support as described in ◆ the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). Consult a mental health specialist if available. » 3. Care for the carers as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) 4. Maintain regular contact and follow-up Make sure there is a » concrete plan for follow-up sessions and that the carers take responsibility for ensuring follow-up (>> Principles of Management in General Principles of Care). Maintain » regular contact (e.g. via telephone, text messages or home visits) with the person. Follow up frequently in the beginning (e.g. weekly » for the first 2 months) and decrease frequency as the person improves (every 2–4 weeks). F » ollow up for as long as the suicide risk persists. At every contact, routinely assess suicidal thoughts and plans.

53 O TH Other Significant Mental Health Complaints OTH While this guide has covered key mental, neurological and substance use (MNS) conditions relevant to humanitarian settings, it does not cover all possible mental health conditions that can occur. Therefore, this module aims to provide basic guidance on initial support for adults, adolescents and children who suffer from mental health complaints that are not covered elsewhere in this guide. Other mental health complaints include (a) various physical symptoms that do not have physical causes and (b) mood and behaviour changes that cause concern but do not fully meet the criteria of the conditions covered in other modules of this guide. These may include complaints involving mild depressive disorder and a range of subclinical conditions. Other mental health complaints are considered significant when they impair daily functioning or when the person seeks help for them. 54 O TH Assessment question 1: Is there a physical cause that fully explains the presenting symptoms? Manage any physical cause identified and recheck » if the symptoms persist. Assessment Conduct a general » physical examination followed by appropriate medical investigations. Assessment question 2: Is this an MNS condition discussed in another module of this guide? Exclude: » Significant symptoms acute stress ◆ (>> ACU) Core features: ▸ potentially traumatic event within the last month ∙ symptoms started after the event ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Significant symptoms grief ◆ (>> GRI) Core features: ▸ symptoms started after a major loss ∙ help-seeking to relieve symptoms or has ∙ considerable difficulty with daily functioning because of the symptoms. Moderate-severe depressive disorder ◆ (>> DEP) Core features (for at least 2 weeks): ▸ persistent depressed mood ∙ markedly diminished interest or pleasure in ∙ activities, especially those that were previously enjoyable considerable difficulty with daily functioning ∙ because of the symptoms. Post-traumatic stress disorder ◆ (>> PTSD) Core features: ▸ potentially traumatic event that happened more ∙ than a month ago recurring frightening dreams, flashbacks* or ∙ intrusive memories* of the events accompanied by intense fear or horror deliberate avoidance of reminders of the event ∙ heightened sense of current threat (excessive ∙ concern and alertness to danger or reacting strongly to loud noises or unexpected movements) considerable difficulty with daily functioning ∙ because of the symptoms. Harmful alcohol or drug use ◆ (>> SUB) Core feature: ▸ use of alcohol or drugs that is causing harm to ∙ self and/or others. Suicide/self-harm ◆ (>> SUI) Core features: ▸ current acts of self-harm; current thoughts and ∙ plans of suicide, or recent thoughts, plans and acts of self-harm in ∙ a person who is severely distressed, agitated, unwilling to communicate or withdrawn. If » any of the above conditions are suspected, then go to the appropriate module for assessment and management. If » 1) physical causes are excluded, 2) the above MNS conditions are excluded and 3) the person is seeking help to relieve symptoms or has considerable difficulty with daily functioning because of their symptoms, then the person has another significant mental health complaint. It usually takes more than one meeting to exclude ◆ physical causes and the above MNS conditions. Assessment question 3: If the person is an adolescent, is there a behavioural problem? Interview both the adolescent and the carers to assess » for persistent or concerning behavioural problems. Examples include: Initiating violence ◆ Drug use ◆ Bullying or being cruel to peers ◆ Vandalism ◆ Risky sexual behaviour. ◆ If the adolescent has a behaviour problem, ask further » questions about: Extreme stressors in the adolescent’s past or current ◆ life (e.g. sexual abuse) Parenting (inconsistent or harsh discipline, limited ◆ emotional support, limited monitoring, mental condition in the carer) How the adolescent spends most of his or her time. ◆ Ask: (if the adolescent works or goes to school) ▸ How do you spend your time after work/school? Are there any regular activities that you do? Are you often bored? ▸ What do you do when you are bored? 55 O TH DO NOT prescribe medicines for “other significant mental health complaints” (unless advised by a specialist). DO NOT give vitamin injections or other ineffective treatments. Basic Management Plan 1. In all cases (whether the person presents with emotional, physical or behavioural problems), provide basic psychosocial support as described in the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) Address current psychosocial stressors. » Strengthen » social support. 2. When no physical condition is identified that fully explains a presenting somatic symptom, acknowledge the reality of the symptoms and provide possible explanations DO NOT order more laboratory or other investigations » unless there is a clear medical indication (e.g. abnormal vital signs). Ordering unnecessary clinical investigations may ◆ reinforce the person’s belief that there is a physical problem. Clinical investigations can have adverse side-effects. ◆ Inform » the person that no serious disease has been identified. Communicate the normal clinical and test findings. We did not find any serious physical problem. ◆ I do not see a need for any more tests at this point. If » the person insists on further investigations, consider saying: Performing unnecessary investigations can be harmful ◆ because they can cause unnecessary worry and side-effects. Ack » nowledge that the symptoms are not imaginary and that it is still important to address symptoms that cause significant distress. Ask » for the person’s own explanation for the cause of the symptoms. This may give clues as to the cause, help build a trusting relationship with the person and increase the person’s adherence to management. Explain » that emotional suffering/stress often involves the experience of bodily sensations (stomach ache, muscle tension, etc.). Ask for and discuss potential links between the person’s emotions/stress and symptoms. Enc » ourage continuation of (or gradual return to) daily activities. Reme » mber also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care). 3. If the person is an adolescent who has behaviour problems Take time to listen » to the adolescent’s own perception of the problem (preferably do this without the presence of the carers). Pr » ovide psychoeducation to the adolescent and their carers. Explain the following: Adolescents sometimes develop problematic ◆ behaviours when they are angry, bored, anxious or sad. They need continuous care and support despite their behaviour. Carers should make every effort to communicate with ◆ the adolescent, even that it is difficult. Specific messages ◆ for the carers: Try to identify positive, enjoyable activities that ▸ you can do together. Be consistent with respect to what the adolescent ▸ is allowed to do and not allowed to do. Praise or reward the adolescent for good ▸ behaviours and correct only the most problematic behaviours. Never use physical punishment. Use praise for good ▸ behaviour more than punishment for bad. Do not confront the adolescent when you are very ▸ upset. Wait until you are calm. Specific points for discussion with the adolescent: ◆ There are healthy ways to deal with boredom, stress ▸ or anger (e.g. doing activities that are relaxing, being physically active, engaging in community activities). It can be helpful to talk to trusted people about ▸ feeling angry, bored, anxious or sad. Alcohol and other substance use can worsen feelings ▸ of anger and depression and should be avoided. Promote » participation in: Formal and informal education ◆ Concrete, purposeful, common interest activities (e.g. ◆ constructing shelters) Structured sports programmes. ◆ Re » member also to apply the Principles of Reducing Stress and Strengthening Social Support (>> General Principles of Care) to this group of adolescents and their carers. Teach stress management. » 4. Follow-up Advise the person to come back if the symptoms persist, » worsen or become intolerable. If no improvement is seen or the person or the carer » insists on further investigations and treatment, consult a specialist. 56 5. Moderate-severe emotional disorder/depression This person’s daily normal functioning is markedly impaired for more than 2 weeks due to a) overwhelming sadness/apathy and/or b) exaggerated, uncontrollable anxiety/fear. Personal relationships, appetite, sleep and concentration are often affected. The person may complain of severe fatigue and be socially withdrawn, often staying in bed for much of the day. Suicidal thinking is common. This category includes people with disabling forms of depression, anxiety disorders and post-traumatic stress disorder (characterized by re-experiencing, avoidance and hyper-arousal). Presentations of milder forms of these disorders are classified as “other psychological complaint”. 6. Other psychological complaint This category covers complaints related to emotions (e.g. depressed mood, anxiety), thoughts (e.g. ruminating, poor concentration) or behaviour (e.g. inactivity, aggression, avoidance). The person tends to be able to function in most day-to-day, normal activities. The complaint may be a symptom of a less severe emotional disorder (e.g. mild forms of depression, of anxiety disorder or of post-traumatic stress disorder) or may represent normal distress (i.e. no disorder). Inclusion criteria: This category should only be applied if a) if the person is requesting help for the complaint and b) if the person is not positive for any of the above 5 categories. 7. Medically unexplained somatic complaint This category covers any somatic/physical complaint that does not have an apparent organic cause. Inclusion criteria: This category should only be applied a) after conducting necessary physical examinations, b) if the person is not positive for any of the above 6 categories and c) if the person is requesting help for the complaint. Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions 1. Epilepsy/seizures A person with epilepsy has at least 2 episodes of seizures not provoked by any apparent cause such as fever, infection, injury or alcohol withdrawal. These episodes are characterized by loss of consciousness with shaking of the limbs and sometimes associated with physical injuries, bowel/bladder incontinence and tongue biting. 2. Alcohol or other substance use disorder A person with this disorder seeks to consume alcohol or other addictive substances and has difficulties controlling consumption. Personal relationships, work performance and physical health often deteriorate. The person continues consuming alcohol or other addictive substances despite these problems. 3. Intellectual disability The person has very low intelligence, causing problems in daily living. As a child, this person is slow in learning to speak. As an adult, the person can work if tasks are simple. Rarely will this person be able to live independently or look after themselves and/or dependants without support from others. When the disability is severe, the person may have difficulties speaking and understanding others and may require constant assistance. 4. Psychotic disorder (including mania) The person may hear or see things that are not there or strongly believe things that are not true. They may talk to themselves, their speech may be confused or incoherent and their appearance unusual. They may neglect themselves. Alternatively, they may go through periods of being extremely happy, irritable, energetic, talkative and reckless. The person’s behaviour is considered “crazy”/highly bizarre by other people from the same culture. This category includes acute psychosis, chronic psychosis, mania and delirium. 57 Annex 2: Glossary 10 11 Ascites Abnormal accumulation of fluid in the abdomen, from various causes. Akathisia A subjective sense of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still). Amphetamines Group of drugs that have a stimulant effect on the central nervous system. They can heighten mental alertness and sense of being awake. They may be used as the basis of treatment for some health conditions but are also drugs of abuse that can produce hallucinations, depression and cardiovascular effects. Behavioural activation Psychological treatment that focuses on improving mood by engaging again in activities that are task-oriented and used to be enjoyable, in spite of current low mood. It may be used as a stand-alone treatment, and it is also a component of cognitive behavioural therapy. Benzodiazepines Class of medicines that have sedative (sleep-inducing), anti-anxiety, anticonvulsant and muscle-relaxing properties. Bipolar disorder Severe mental disorder characterized by alternation between manic and depressive episodes. Bone marrow depression Suppression of bone marrow function, which can lead to deficiencies in blood cell production. Cannabis General name for parts of the hemp plant, from which marijuana, hashish and hash oil are derived. These are either smoked or eaten to induce euphoria, relaxation and altered perceptions. They may reduce pain. Harmful effects include demotivation, agitation and paranoia. Cerebral palsy Disorder of motor and intellectual abilities caused by early permanent damage to the developing brain. Cognitive Mental processes associated with thinking. These include reasoning, remembering, judgement, problem-solving and planning. Cognitive behavioural therapy (CBT) Psychological treatment that combines cognitive components (aimed at thinking differently, for example through identifying and challenging unrealistic negative thoughts) and behavioural components (aimed at doing things differently, for example by helping the person to do more rewarding activities). Cognitive behavioural therapy with a trauma focus (CBT-T) Psychological treatment based on the idea that people who were exposed to a traumatic event have unhelpful thoughts and beliefs related to that event and its consequences. These thoughts and beliefs result in unhelpful avoidance of the reminders of the event and a sense of current threat. The treatment usually includes exposure to those reminders and challenging unhelpful trauma-related thoughts or beliefs. Community-based rehabilitation (CBR) Set of interventions delivered through a multi-sectoral strategy in community settings, using available community resources and institutions. It aims to achieve rehabilitation by enhancing the quality of life for people with disabilities and their families, meeting basic needs and ensuring inclusion and participation. Delirium Transient fluctuating mental state characterized by disturbed attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (i.e., reduced orientation to the environment) that develops over a short period of time and tends to fluctuate during the course of a day. It is accompanied by (other) disturbances of perception, memory, thinking, emotions or psychomotor functions. It may result from acute organic causes such as infections, medication, metabolic abnormalities, substance intoxication or substance withdrawal. Delusion Fixed belief that is contrary to available evidence. It cannot be changed by rational argument and is not accepted by other members of the person’s culture or subculture (i.e., it is not an aspect of religious faith). Dependence People are dependent on a substance (drugs, alcohol or tobacco) when they develop uncomfortable cognitive, behavioural and physiological symptoms in its absence. These withdrawal symptoms result in their seeking to take more of that substance. They cannot control their substance use and continue despite adverse consequences. Dilated /constricted pupils The pupil (black part of the eye) is the opening in the centre of the iris that regulates the amount of light getting into the eye. Pupils normally constrict (shrink) in light to protect the back of the eye and dilate (enlarge) in the dark to allow maximum light into the eye. Having dilated or constricted pupils can be a sign of being under the influence of drugs. Down syndrome A genetic condition caused by the presence of an extra chromosome 21. It is associated with varying degrees of intellectual disability, delayed physical growth and characteristic facial features. 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). 58 Drug-disease interaction Situation where a drug prescribed to treat one health condition affects another health condition in the same person. Drug-drug interaction Situation where two drugs taken by the same person interact with each other, altering the effect of either or both drugs. Interactions can include lessening the effect of a drug, enhancing or speeding up an effect, or having a toxic effect. Extrapyramidal side- effects Abnormalities in muscle movement, mostly caused by antipsychotic medication. These include muscle tremors, stiffness, spasms and/or akathisia. Eye movement desensitisation and reprocessing (EMDR) Psychological treatment based on the idea that negative thoughts, feelings and behaviours result from unprocessed memories of traumatic events. The treatment involves standardized procedures that include focusing simultaneously on (a) associations of traumatic images, thoughts, emotions and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Flashback An episode where the person believes and acts for a moment as though they are back at the time of the event, living through it again. People with flashbacks briefly lose touch with reality, usually for a few seconds or minutes. Hallucination False perception of reality: seeing, hearing, feeling, smelling or tasting things that are not real. Hepatic encephalopathy Abnormal mental state including drowsiness, confusion or coma caused by liver dysfunction. Hyperthyroidism Condition in which the thyroid gland produces and secretes excessive amounts of thyroid hormones. Some of the symptoms of this condition such as delirium, tremors, high blood pressure and increased heart rate may be confused with alcohol withdrawal. Hyperventilation Breathing abnormally fast, resulting in hypocapnia (too little CO2 in the blood). This can produce characteristic symptoms of tingling or having a sensation of pins and needles in the fingers and around the mouth, chest pain and dizziness. Hypoglycaemia Abnormally low concentration of glucose (sugar) in the blood. Hyponatraemia Abnormally low concentration of sodium (salt) in the blood. Hypothyroidism Abnormally low activity of the thyroid gland. In adults, it can cause a range of symptoms such as fatigue, lethargy, weight gain and low mood that can be confused with depression. If present at birth and untreated, it may lead to intellectual disability and failure to grow. Interpersonal therapy (IPT) Psychological treatment that focuses on the link between depressive symptoms and interpersonal problems, especially those involving loss, conflict, isolation and major life changes. Intrusive memories Recurrent, unwanted, distressing memories of a traumatic event. Iodine deficiency Condition where the body lacks iodine required for normal production of thyroid hormone, affecting growth and development. Khat Leaves of the shrub Catha edulis, containing a stimulant substance. It is both a recreational drug and a drug of abuse and can create dependence. Log-roll Method of turning a person from one side to another without bending their neck or back, in order to prevent spinal cord damage. Medically unexplained paralysis Partial or total loss of strength in any part of the body without any identifiable organic cause. Meningeal irritation Irritation of the layers of tissue that cover the brain and spinal cord, usually caused by an infection. Metabolic abnormality Abnormality in the body’s hormones, minerals, electrolytes or vitamins. Mourning The processes through which a bereaved person pays attention, bids farewell and memorialises the dead, both in private and in public. Mourning usually involves rituals such as funerals and customary behaviours such as changing clothing, remaining at home and fasting. Neuroinfection Infection involving the brain and/or spinal cord. Neuroleptic malignant syndrome A rare but life-threatening condition caused by antipsychotic medications, which is characterised by fever, delirium, muscular rigidity and high blood pressure. Non-steroidal anti- inflammatory drugs (NSAIDs) Group of drugs used to suppress inflammation. They are often used for pain relief (for example, ibuprofen is an NSAID). Opiate Narcotic drug derived from the opium poppy. Opiates are very effective painkillers but can be addictive and create dependence. Heroin is an opiate. Orthostatic hypotension Sudden drop of blood pressure that can occur when one changes position from lying to sitting or standing up, usually leading to feelings of light-headedness or dizziness. It is not life-threatening. 59 Polytherapy Provision of more than one medicine at the same time for the same condition. Potentially traumatic event Any threatening or horrific event such as physical or sexual violence, witnessing of an atrocity, destruction of a person’s house, or major accidents or injuries. Whether or not these kinds of event are experienced as traumatic will depend on the person’s emotional response. Problem-solving counselling Psychological treatment that involves the systematic use of problem identification and problem-solving techniques over a number of sessions. Problem-solving techniques Techniques that involve working together with a person to brainstorm solutions and coping strategies for identified problems, prioritizing them, and discussing how to implement these solutions and strategies. In mhGAP the term “problem-solving counselling” is used when these techniques are used systematically over a number of sessions. “Pseudoseizure” An episode that appears to be an epileptic seizure but actually is not. They can mimic epileptic seizures closely in terms of changes in consciousness and movements, although tongue biting, serious bruising due to falling, and incontinence of urine are rare. Such episodes do not show the electrical activity of epileptic seizures. Symptoms are not due to a neurological condition or to the direct effects of a substance or medication. In ICD-11 proposals, these episodes are covered under dissociative motor disorder. Psychological first aid (PFA) Provision of supportive care to people in distress who have recently been exposed to a crisis event. The care involves assessing immediate needs and concerns; ensuring that immediate basic physical needs are met; providing or mobilizing social support; and protecting from further harm. Regressive behaviour Behaviour that is inappropriate to a child’s actual developmental age but would be appropriate for someone younger. Common examples are bedwetting and clinginess in children. Respiratory depression Inadequate slow breathing rate, resulting in insufficient oxygen. Common causes include brain injury and intoxication (e.g. due to benzodiazepines). Seizure Episode of brain malfunction due to abnormal electrical discharges. Self-harm Intentional self-inflicted poisoning or injury to oneself, which may or may not have a fatal intent or outcome. Self-medicating Self-administering alcohol or drugs (including prescribed medicines) to reduce physical or psychological problems without consulting a health professional. Sepsis Life-threatening condition caused by severe infection, with signs such as fever, disruption of the circulatory system and dysfunction of organs. Shock Condition where a person’s circulatory system collapses as a result of an infection or other toxins whereby the blood pressure may drop to a level unsustainable for survival. Signs include low or undetectable blood pressure, cold skin, a weak or absent pulse, troubled breathing and altered level of consciousness. SSRI Selective serotonin reuptake inhibitors: class of antidepressant drugs that selectively block the reuptake of serotonin. Serotonin is a chemical messenger (neurotransmitter) in the brain that is thought to affect a person’s mood. Fluoxetine is an SSRI. Steroids A group of hormones available as medication that have important functions including suppressing inflammatory reactions to infections, toxins and other immune-related disorders. Examples of steroid medication include glucocorticoids (e.g., prednisolone) and hormonal contraceptives. Stevens-Johnson syndrome Life-threatening skin condition characterized by painful skin peeling, ulcers, blisters and crusting of mucocutaneous tissues such as mouth, lips, throat, tongue, eyes and genitals, sometimes associated with fever. It is most often caused by severe reaction to medications, especially antiepileptic drugs. Suicide The act of deliberately causing one’s own death. TCA Tricyclic antidepressants: class of antidepressant drugs that block the reuptake of the neurotransmitters noradrenaline and serotonin. Examples include amitriptyline and clomipramine. Tolerance Diminishing effect of a drug when used at the same dose. It results from the body’s habituation to the drug due to repeated consumption. Higher doses are then required to create the same effect. Toxic epidermal necrolysis Life-threatening skin peeling that is usually caused by a reaction to a medicine or infection. It is similar to but more severe than Stevens-Johnson syndrome. Tramadol Prescribed opioid used to relieve pain. It is sometimes misused because it can induce feelings of euphoria (feeling “high” or happy). Tremor Trembling or shaking movements, usually of the fingers. Urosepsis Sepsis caused by urinary tract infection. 60 Annex 3: Symptom Index Anxiety Acute Stress (ACU) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Appetite problem Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Bedwetting Acute Stress (ACU) Intellectual Disability (ID) Confusion Psychosis (PSY) Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Delusions Psychosis (PSY) Difficulty carrying out usual activities Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Flashbacks Acute Stress (ACU) Post-traumatic Stress Disorder (PTSD) Hallucinations Psychosis (PSY) Harmful Use of Alcohol and Drugs (SUB) Hopelessness Grief (GRI) Moderate-severe Depressive Disorder (DEP) Suicide (SUI) Hyperventilation Acute Stress (ACU) Incontinence Epilepsy/Seizures (EPI) Intellectual Disability (ID) Insomnia Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Intrusive memories Acute Stress (ACU) Grief (GRI) Post-traumatic Stress Disorder (PTSD) Irritability Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Learning problem Intellectual Disability (ID) Loss of energy Grief (GRI) Moderate-severe Depressive Disorder (DEP) 61 Low interest, pleasure Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Poor hygiene Psychosis (PSY) Intellectual Disability (ID) Harmful Use of Alcohol and Drugs (SUB) Reduced concentration Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) Harmful Use of Alcohol and Drugs (SUB) Sad mood Grief (GRI) Moderate-severe Depressive Disorder (DEP) Seizures, convulsions Epilepsy/Seizures (EPI) Harmful Use of Alcohol and Drugs (SUB) Self-harm Suicide (SUI) Social withdrawal Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Psychosis (PSY) Unexplainable physical symptoms Acute Stress (ACU) Grief (GRI) Moderate-severe Depressive Disorder (DEP) Post-traumatic Stress Disorder (PTSD) mental health Gap Action Programme In every general health facility in humanitarian emergencies at least one supervised health care-staff member should be capable to assess and manage mental, neurological and substance use conditions. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG) is a simple, practical resource that aims to ensure this target.

Лечение психических и неврологических расстройств и расстройств, связанных с употреблением наркотиков и других веществ, в чрезвычайных гуманитарных ситуациях Руководство по гуманитарной помощи Программы действий ВОЗ по ликвидации пробелов в области охраны психического здоровья (mhGAP-HIG) Программа действий ВОЗ по ликвидации пробелов в области психического здоровья WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1. Mental Disorders. 2. Substance-related Disorders. 3. Nervous System Diseases. 4. Relief Work. 5. Emergencies. I.World Health Organization. II.UNHCR. ISBN 978 92 4 454892 9 (NLM classification: WM 30) © Всемирная организация здравоохранения, 2016 г. Все права защищены. Публикации Всемирной организации здравоохранения имеются на веб-сайте ВОЗ (www.who.int) или могут быть приобретены в Отделе прессы ВОЗ, Всемирная организация здра- воохранения, 20 Avenue Appia, 1211 Geneva 27, Switzerland (тел.: +41 22 791 3264; факс: +41 22 791 4857; эл. почта: bookorders@who.int). Запросы на получение разрешения на воспроизведение или перевод публикаций ВОЗ - как для продажи, так и для некоммерческого распространения - следует направлять в Отдел прессы ВОЗ через веб-сайт ВОЗ (http://www.who.int/about/licensing/copyright_form/en/index.html). Обозначения, используемые в настоящей публикации, и приводимые в ней материалы не отражают какого-либо мнения Всемирной организации здравоохранения относительно юридического статуса какой-либо страны, территории, города или района или их органов власти, либо относительно делими- тации их границ. Пунктирные линии на географических картах обозначают приблизительные границы, в отношении которых пока еще может быть не достигнуто полное согласие. Упоминание конкретных компаний или продукции некоторых изготовителей не означает, что Всемир- ная организация здравоохранения поддерживает или рекомендует их, отдавая им предпочтение по сравнению с другими компаниями или продуктами аналогичного характера, не упомянутыми в тексте. За исключением случаев, когда имеют место ошибки и пропуски, названия патентованных продуктов выделяются начальными прописными буквами. Всемирная организация здравоохранения приняла все разумные меры предосторожности для провер- ки информации, содержащейся в настоящей публикации. Тем не менее, опубликованные материалы распространяются без какой-либо четко выраженной или подразумеваемой гарантии. Ответственность за интерпретацию и использование материалов ложится на пользователей. Всемирная организация здравоохранения ни в коем случае не несет ответственности за ущерб, возникший в результате исполь- зования этих материалов. iСегодня в мире возникает беспрецедентное количество чрезвычайных гуманитарных ситуаций, связан- ных с вооруженными конфликтами и стихийными бедствиями. Со времени окончания Второй мировой войны не наблюдалось такого количества беженцев и внутренне перемещенных лиц. Десятки миллионов человек – в особенности в странах Ближнего Востока, Африки и Азии –остро нуждаются в помощи, и особенно в психологической и психиатрической помощи. В чрезвычайных ситуациях у детей и взрослых развивается множество различных психических и невро- логических расстройств, а также расстройств, связанных с употреблением наркотиков и других веществ. Горе и острое стрессовое расстройство поражают большинство людей и считаются естественными преходящими психологическими реакциями на крайне тяжелые обстоятельства. Однако у меньшинства подобные обстоятельства вызывают психические расстройства, такие как депрессивное расстройство, посттравматическое стрессовое расстройство или пролонгированная реакция горя, которые могут силь- но мешать повседневной деятельности. Кроме того, люди с уже существующими тяжелыми заболевания- ми, такими как психоз, умственная отсталость и эпилепсия, становятся еще более уязвимыми. Это может быть вызвано перемещением в другую местность, отсутствием должного внимания и отсутствием доступа к медицинской помощи. Наконец, употребление алкоголя и наркотиков создает серьезный риск проблем со здоровьем и гендерного насилия. И когда потребности населения в области психического здоровья существенно возрастают, соответствующих местных ресурсов здравоохранения часто не хватает. В таких условиях как никогда нужны практические и легкие в использовании инструменты. Настоящее руководство рассчитано на подобные ситуации. «Руководство по гуманитарной помощи mhGAP» – простой практический инструмент, призванный помочь неспециализированным медицинским учреждениям в зонах чрезвычайных гуманитарных ситуаций в оценке и лечении больных с психически- ми и неврологическими расстройствами и расстройствами, связанными с употреблением наркотиков и других веществ. Оно основано на Руководстве mhGAP по принятию мер в отношении психических и не- врологических расстройств ВОЗ (2010 г.), составленном с учетом фактических данных и широко использу- емом для ведения пациентов с такими состояниями в неспециализированных медицинских учреждениях, и предназначено для применения в чрезвычайных гуманитарных ситуациях. Настоящее руководство полностью согласуется с «Руководящими принципами Межучрежденческого по- стоянного комитета (МПК)» и «Оперативными руководящими принципами УВКБ ООН по охране психиче- ского здоровья и психосоциальной поддержке беженцев», которые требуют межсекторальных ответных мер для преодоления психических и социальных последствий чрезвычайных гуманитарных ситуаций и перемещения населения в другую местность. Оно также способствует выполнению основной задачи Комплексного плана действий в области психического здоровья ВОЗ на период 2013–2020 гг., а именно созданию всесторонней, комплексной и оперативной системы охраны психического здоровья и социаль- ной поддержки во внебольничных условиях. Мы призываем всех партнеров по гуманитарной деятельности в секторе здравоохранения принять и рас- пространить это важное руководство, помочь уменьшить страдания и расширить возможности взрослых и детей с особыми потребностями в сфере психического здоровья в условиях чрезвычайных гуманитар- ных ситуаций. Маргарет Чен Генеральный директор Всемирная организация здравоохранения António Guterres Верховный комиссар ООН по делам беженцев

iii Выражение благодарности . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Введение . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Советы руководителям клиник . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Общие Принципы оказания помощи людям с психическими и неврологическими расстройствами и расстройствами, связанными с употреблением наркотиков и других веществ, в условиях чрезвычайных гуманитарных ситуаций . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1. Принципы общения . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Принципы оценки . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3. Принципы лечения . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4. Принципы снижения стресса и укрепления социальной поддержки . . . . . . . . . . . . . . . . . . . 8 5. Принципы защиты прав человека . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 6. Принципы заботы об общем благополучии . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Модули 1. Острое стрессовое расстройство (ОСР). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2. Горе (ГОРЕ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3. Депрессивное расстройство средней или тяжелой степени (ДЕП) . . . . . . . . . . . . . . . . . . . . . 21 4. Посттравматическое стрессовое расстройство (ПТСР) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 5. Психоз (ПСИ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 6. Эпилепсия/Припадки (ЭПИ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 7. Умственная отсталость (УО). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 8. Пагубное употребление алкоголя и наркотических средств (ВЕЩ) . . . . . . . . . . . . . . . . . . . . 47 9. Суицид (СУИ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 10. Прочие значимые жалобы, связанные с психическим здоровьем (ПРОЧ) . . . . . . . . . . . . . . . . 57 Приложения Приложение 1. Определения случаев в соответствии с системой медико-санитарной информации УВКБ ООН (2014 г.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Приложение 2. Словарь терминов . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Приложение 3. Указатель симптомов . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 iv Разработка концепции Mark van Ommeren (ВОЗ), Yutaro Setoya (ВОЗ), Peter Ventevogel (УВКБ ООН) и Khalid Saeed (ВОЗ), под руководством Shekhar Saxena (ВОЗ) и Marian Schilperoord (УВКБ ООН) Составление проекта и редакционная коллегия Peter Ventevogel (УВКБ ООН), Ka Young Park (Гарвардский институт государственного управления им. Джона Ф. Кеннеди) и Mark van Ommeren (ВОЗ) Рабочая группа mhGAP ВОЗ Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright и M. Taghi Yasamy Прочие соавторы/рецензенты Helal Uddin Ahmed (Национальный институт психического здоровья, Бангладеш), Corrado Barbui (Сотрудничающий центр ВОЗ по исследованиям и обучению в области психического здоровья, Веронский университет), Thomas Barrett (Денверский университет), Pierre Bastin (Международный комитет Красного Креста), Myron Belfer (Гарвардская медицинская школа), Margriet Blaauw (Целевая группа МПК по охране психического здоровья и психосоциальной поддержке в чрезвычайных ситуациях), Boris Budosan (Мальтийский Интернационал), Kenneth Carswell (ВОЗ), Jorge Castilla (ECHO, Европейская комис- сия), Vanessa Cavallera (ВОЗ), Elizabeth Centeno-Tablante (ВОЗ), Lukas Cheney (Мельбурнский университет), Rachel Cohen (Common Threads), Ana Cuadra («Врачи мира», MdM), Katie Dawson (Университет Нового Южного Уэльса), Joop de Jong (Амстердамский университет), Pamela Dix (Disaster Action), Frederique Drogoul («Врачи без границ», MSF), Carolina Echeverri (УВКБ ООН), Rabih El Chammay (Министерство здравоохранения, Ливан), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Колумбийский университет), Richard Garfield (Центры контроля и профилактики заболеваний, CDC), Anne Golaz (Женевский университет), David Goldberg (Королевский колледж, Лондон), Marlene Goodfriend (MSF), Margaret Grigg (MIND, Австралия), Norman Gustavson (PARSA, Афганистан), Fahmy Hanna (WHO), Mathijs Hoogstad (не в качестве сотрудника какой-либо организации, Нидерланды), Peter Hughes (Королевский колледж психиатров, Велико- британия), Takashi Izutsu (Всемирный банк), Lynne Jones (Гарвардская школа здравоохранения), Devora Kestel (Панамери- канская организация здравоохранения/ВОЗ), Louiza Khourta (УВКБ ООН), Cary Kogan (Оттавский университет), Roos Korste (in2mentalhealth, Нидерланды), Marc Laporta (Университет Макгилла), Jaak Le Roy (не в качестве сотрудника какой-либо организации, Бельгия), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights, Израиль), Andreas Maercker (Цюрихский университет), Heini Mäkilä (Миссия международного содействия, Афганистан), Adelheid Marschang (ВОЗ), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Университет здоровья и сопутствующих дисциплин Мухимбили, Танзания), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Малайзия), Emilio Ovuga (Университет Гулу, Уганда), Sarah Pais (ВОЗ), Heather Papowitz (ЮНИСЕФ), Xavier Pereira (Медицинский факультет Университета Тэйлорс и Health Equity Initiatives, Малайзия), Pau Perez-Sales (Больница Ла-Пас, Испания), Giovanni Pintaldi (MSF), Bhava Poudyal (не в качестве сотрудника ка- кой-либо организации, Азербайджан), Rasha Rahman (ВОЗ), Ando Raobelison (World Vision International), Nick Rose (Оксфорд- ский университет), Cecile Rousseau (Университет Макгилла), Khalid Saeed (ВОЗ), Benedetto Saraceno (Новый лиссабонский университет, Португалия), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (Университет Нового Южного Уэльса), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (Национальный институт психического здоровья, Япония), Saji Thomas (ЮНИСЕФ), Ana María Tijerino (MSF), Wietse Tol (Университет Джона Хопкинса и Фонд им. Питера К. Олдермана), Senop Tschakarjan (MdM), Bharat Visa (ВОЗ), Inka Weissbecker (IMC), Nana Wiedemann (Международная федерация Красного Креста) и William Yule (Королевский колледж, Лондон). Финансирование Управление верховного комиссара ООН по делам беженцев (УВКБ ООН) Дизайн Elena Cherchi 1Настоящее руководство – версия «Руководства mhGAP ВОЗ по принятию мер в отношении психических и неврологических расстройств и расстройств, связанных с употреблением наркотиков и других веществ, в неспециализированных меди- цинских учреждениях», адаптированная для использования в чрезвычайных гуманитарных ситуациях. Соответственно, оно называется «Руководство по гуманитарной помощи mhGAP» (mhGAP-HIG). 1 Для получения экземпляров этих инструментов напишите по адресу mhgap-info@who.int. 2 См. Всемирная организация здравоохранения (ВОЗ). «Восстановить и улучшить: устойчивая охрана психического здоровья после чрезвычайных ситуаций». ВОЗ: Женева, 2013 г. Программа действий ВОЗ по ликвидации пробелов в обла- сти охраны психического здоровья (mhGAP) – программа ВОЗ, направленная на компенсацию нехватки медицинской помощи людям, страдающим от психических и неврологиче- ских расстройств, а также расстройств, связанных с употре- блением наркотиков и других веществ (ПНВ). В рамках этой программы в 2010 г. было выпущено «Руководство mhGAP по принятию мер в отношении психических и неврологиче- ских расстройств» (mhGAP-IG). Руководство mhGAP-IG – кли- ническое руководство по психическим и неврологическим расстройствам, а также расстройствам, связанным с употре- блением наркотиков и других веществ, для медицинских работников общего профиля, работающих в неспециали- зированных медицинских учреждениях, в особенности в странах с низким и средним уровнем доходов. К ним отно- сятся врачи общей практики, медсестры, акушерки и клини- цисты, а также врачи, не специализирующиеся в психиатрии и неврологии. Помимо клинического руководства, программа mhGAP пре- доставляет ряд инструментов, облегчающих ее реализацию и полезных для анализа ситуации, адаптации клинических протоколов к местным особенностям, планирования про- грамм, обучения, контроля и мониторинга1. Почему нужно адаптироваться к условиям гуманитарных чрезвычайных ситуаций? Чрезвычайные гуманитарные ситуации включают широкий спектр кратковременных и длительно сохраняющихся чрезвычайных ситуаций, вызванных вооруженными кон- фликтами, а также природными и промышленными катастро- фами. Чрезвычайные гуманитарные ситуации часто сопро- вождаются массовым перемещением населения в другую местность. В таких условиях потребности населения в базовых услугах превышают местные возможности, по- скольку местная система может быть повреждена вследствие чрезвычайной ситуации. Имеющиеся ресурсы зависят от мас- штаба и доступности местной, национальной или междуна- родной гуманитарной помощи. Гуманитарный кризис создает ряд проблем, а также предо- ставляет медицинским работникам уникальные возможно- сти. Возможности включают усиление политической воли и увеличение ресурсов для оказания и улучшения услуг в области охраны психического здоровья2. Проблемы включают: » повышенную срочность расстановки приоритетов и рас- пределения скудных ресурсов; » ограниченное время на обучение медицинских работников; » ограниченный доступ к специалистам (для обучения, контроля, менторства, направления к специалистам или консультации с ними); » ограниченный доступ к лекарственным средствам в связи с нарушением обычных каналов поставок. «Руководство по гуманитарной помощи mhGAP» было разра- ботано для решения этих проблем, характерных для гумани- тарных чрезвычайных ситуаций. Содержание этого руководства «Руководство по гуманитарной помощи mhGAP» содержит рекомендации для медицинских работников общего профиля по первоочередному лечению расстройств ПНВ в чрезвычайных гуманитарных ситуациях, когда ограничен доступ к специалистам и ограничены возможности лечения. Это руководство представляет собой выдержки самой важ- ной информации из полной версии документа mhGAP-IG и включает дополнительные элементы, характерные для условий гуманитарных чрезвычайных ситуаций. Это руководство охватывает: » советы руководителям клиник; » общие принципы оказания помощи в условиях гуманитар- ных чрезвычайных ситуаций, в том числе:  оказание многосекторальной поддержки в соответствии с «Руководящими принципами МПК по охране психиче- ского здоровья и психосоциальной поддержке в чрез- вычайных ситуациях» (МПК, 2007 г.), «Оперативными руководящими принципами по охране психического здоровья и психосоциальной поддержке беженцев» (УВКБ ООН, 2013 г.) и другими инструментами для чрезвы- чайных ситуаций;  инструкции по снижению стресса; » краткие разделы по оценке, лечению и принятию мер в отношении:  острого стрессового расстройства (ОСР);  горя (ГОРЕ);  депрессивного расстройства средней или тяжелой степе- ни (ДЕП);  посттравматического стрессового расстройства (ПТСР);  психоза (ПСИ);  эпилепсии/припадков (ЭПИ);  умственной отсталости (УО);  пагубного употребления алкоголя и наркотических средств (ВЕЩ);  суицида (СУИ);  прочих значимых жалоб, связанных с психическим здоровьем (ПРОЧ). Что такое mhGAP? 2Другие изменения включают: » Руководящие принципы по расстройствам поведения были изменены на руководящие принципы по наруше- ниям поведения у подростков и приведены в разделе о прочих значимых жалобах, связанных с психическим здоровьем (ПРОЧ). » Раздел «Оценка и лечение состояний, связанных исклю- чительно со стрессом: модуль Руководства mhGAP по принятию мер в отношении психических и неврологи- ческих расстройств» (ВОЗ, 2013 г.) был разделен на три части: острое стрессовое расстройство (ОСР), горе (ГОРЕ) и посттравматическое стрессовое расстройство (ПТСР). » Был добавлен список терминов. Определения терминов, отмеченных звездочкой (*), приведены в приложении 2. Это руководство значительно короче, чем руководство mhGAP-IG. Оно не содержит рекомендации относительно: » алкогольной и лекарственной интоксикации и зависимо- сти* (однако в этом руководстве рассказывается о синдро- ме отмены алкоголя и пагубном употреблении алкоголя и наркотических средств); » синдрома дефицита внимания с гиперактивностью (однако в разделе этого руководства по прочим значимым жалобам, связанным с психическим здоровьем, рассматриваются нарушения поведения у подростков); » расстройств аутического спектра; » деменции (однако в «Общих принципах помощи» в этом руководстве даны рекомендации по оказанию поддержки лицам, осуществляющим уход за людьми с любым рас- стройством ПНВ); » ситуаций, не связанных с непосредственным риском само- повреждения; » второочередного лечения большинства расстройств ПНВ. Руководящие принципы по этим вопросам представлены в полном руководстве mhGAP-IG. 3Включение психических и неврологических расстройств, а также расстройств, связанных с употреблением наркотиков и дру- гих веществ (ПНВ), в общую охрану здоровья должно контролироваться руководителем (например, районным инспектором системы здравоохранения, медицинским директором компетентного органа и пр.), ответственным за разработку и координа- цию оказания помощи в нескольких медицинских учреждениях, в зависимости от результатов анализа ситуации (см. инстру- ментарий для оценки ВОЗ и УВКБ ООН [2012 г.]). В каждом учреждении есть руководитель клиники (руководитель медицин- ского учреждения) с соответствующими обязанностями. Руководители клиник должны учитывать следующие аспекты. Обстановка » Выделите специальное место, желательно отдельную комнату, для консультаций по расстройствам ПНВ. Если отдельной комнаты нет, постарайтесь огородить это место занавесками или другим образом для создания уединенной обстановки. » Рассмотрите возможность не ставить никаких опознава- тельных знаков, чтобы люди не избегали услуг, оказывае- мых лицам с ПНВ, из боязни общественного осуждения. Модель оказания услуг » Рассмотрите возможность всегда оставлять на месте хотя бы одного обученного сотрудника в качестве «дежурного по ПНВ», т. е. лица, ответственного за оценку и лечение людей с расстройствами ПНВ. » Либо рассмотрите возможность раз в неделю или раз в две недели организовывать «клинику ПНВ» в неспециа- лизированном медицинском учреждении в те часы, когда это учреждение менее загружено. Людей, приходящих за помощью в часы, когда клиника ПНВ не работает, можно вежливо попросить вернуться в часы ее работы. Органи- зация клиники ПНВ может быть полезна в загруженных медицинских учреждениях, в особенности для проведения первичной оценки, которая обычно занимает больше вре- мени, чем последующие посещения. Набор и обучение сотрудников » Расскажите всем сотрудникам о необходимости создания поддерживающей обстановки для всех людей с расстрой- ствами ПНВ. » Определите, кто из сотрудников пройдет обучение помощи людям с ПНВ. » Убедитесь в наличии ресурсов не только для обучения, но и для контроля. Клинический контроль сотрудников обяза- телен для оказания качественной помощи людям с ПНВ. » Если только несколько человек могут пройти обучение по этому руководству, убедитесь, что остальной персонал может по крайней мере оказать первую психологическую помощь (ППП)*. Ознакомление с принципами ППП занима- ет примерно полдня. «Первая психологическая помощь: руководство для работников на местах» и сопутствую- щие ознакомительные материалы для организаторов выложены в сети Интернет. » Обучите регистратора приемного отделения (или человека на аналогичной должности) обращению с людьми в состоя- нии тревожного возбуждения, которые могут нуждаться в неотложной помощи или требовать ее предоставления. » Обучите работников и волонтеров местного сообщества, если таковые имеются, как а) повысить осведомленность о помощи людям с ПНВ (см. ниже), б) помочь людям с рас- стройствами ПНВ обратиться за помощью в клинику или в) помочь с последующим лечением. » Рассмотрите возможность направить кого-либо из меди- цинских работников (например, медсестру, работника по психосоциальной поддержке, социального работника местного сообщества) на обучение психосоциальной под- держке (например, проведению кратких курсов психотера- пии, организации групп взаимопомощи, обучению управле- нию стрессом) и возложить на этого человека обязанность по оказанию этого вида помощи под контролем другого сотрудника. » Ознакомьте всех сотрудников с местными мероприятия- ми по охране общества:  требования к информированному согласию и его ограни- чения, в том числе сообщение о подозреваемом жесто- ком обращении с детьми, о сексуальном насилии и насилии, совершаемом на основании полового признака, и о других нарушениях прав человека;  Выявление, отслеживание и воссоединение семей. В осо- бенности следует защищать детей, разлученных с семьей, и помогать в организации временного ухода за ними, если он требуется. » Если к клинике с целью контроля прикреплены медицин- ские работники из разных стран, их следует ознакомить с местной культурой и условиями. » Расскажите всем сотрудникам, как направить человека в имеющиеся службы. Направление к специалистам » Убедитесь, что в клинике есть актуальные контактные данные для направления к специалистам для лечения расстройств ПНВ. » Убедитесь, что в клинике есть актуальные контактные данные других доступных источников поддержки в регионе (например, для удовлетворения основных потребностей, таких как убежище и пища, социальные и общественные ресурсы и услуги, защита и юридическая поддержка). 4Повышение осведомленности о доступных услугах » Подготовьте сообщения для местного сообщества о до- ступной помощи ПНВ (например, цель и важность помощи ПНВ, доступные в клинике услуги, местонахождение и часы работы клиники). » Обсудите сообщения с лидерами местного сообщества. » Используйте различные каналы распространения ин- формации, такие как радио, объявления в медицинских учреждениях, работники местного сообщества или другие ресурсы, посредством которых можно проинформировать население. » При необходимости рассмотрите возможность обсудить сообщения с местными врачами, практикующими народ- ную и местную медицину, которые могут оказывать помощь людям с расстройствами ПНВ и могут быть готовы к сотруд- ничеству и направлению некоторых людей к специалистам (принципы см. в «Руководящих принципах МПК по охране психического здоровья и психосоциальной поддержке в чрезвычайных ситуациях» [МПК, 2007 г.]). » Обратитесь к маргинализованным группам, которые могут не знать о клинике или не иметь доступа к ней. Лекарственные средства » Вместе с лицами, принимающими решения, обеспечьте непрерывные поставки жизненно важных лекарствен- ных средств. » Всегда должны быть доступны:  хотя бы один нейролептик (в таблетках и инъекционной форме);  хотя бы одно противопаркинсоническое средство (для устранения потенциальных экстрапирамидных побочных эффектов*) (в таблетках);  хотя бы одно противосудорожное/противоэпилептиче- ское средство (в таблетках);  хотя бы один антидепрессант (в таблетках) и  хотя бы один анксиолитик (в таблетках и инъекционной форме). » У вас может быть доступ к межучрежденческому набору для оказания неотложной медицинской помощи (IEHK) (ВОЗ, 2011 г.), большой коробке с лекарственными сред- ствами и медицинскими изделиями, предназначенными для удовлетворения потребностей в первичной медико-са- нитарной помощи 10 000 человек в условиях чрезвычайной гуманитарной ситуации в течение 3 месяцев. » Набор IEHK содержит следующие психотропные лекар- ственные средства: Амитриптилин в таблетках: таблетки по 25 мг × 4000 Бипериден в таблетках: таблетки по 2 мг × 400 Диазепам в таблетках: таблетки по 5 мг × 240 Диазепам для инъекций: 5 мг/мл, 2 мл/ампула × 200  Галоперидол в таблетках: таблетки по 5 мг × 1300  Галоперидол для инъекций: 5 мг/мл, 1 мл/ампула × 20 Фенобарбитал в таблетках: 50 мг × 1000 » Количество лекарственных средств в наборе IEHK недоста- точно для программ активного выявления и лечения эпи- лепсии, психоза и депрессии. В таких случаях потребуются дополнительные лекарственные средства. » В долгосрочной перспективе необходимое количество лекарственных средств определяется по потребностям. » В дополнение к психотропным препаратам в наличии должен быть атропин для лечения острого отравления пестицидами, частой формы самоповреждения. Атропин входит в состав набора IEHK (1 мг/мл, 1 мл/ампула × 50). » Убедитесь, что все лекарственные средства хранятся в надежном месте. Управление информацией » Обеспечьте конфиденциальность. Медицинские карты следует хранить в надежном месте. » Определите, какие данные нужно вводить в систему меди- ко-санитарной информации.  Рассмотрите возможность использования 7-категорийно- го нейропсихиатрического компонента системы меди- ко-санитарной информации УВКБ ООН для документиро- вания расстройств ПНВ (см. приложение 1).  В острой фазе масштабных чрезвычайных ситуаций лица, принимающие решения в области здравоохранения, могут быть не готовы добавить 7 пунктов в систему ме- дико-санитарной информации. В такой ситуации следует добавить в эту систему хотя бы пункт под названием «психические, неврологические расстройства и рас- стройства, связанные с употреблением наркотиков и дру- гих веществ». Со временем следует заменить этот пункт более подробной классификацией. » Собирайте и анализируйте данные и отчитывайтесь о результатах перед лицами, принимающими решения в области здравоохранения. 5О П П ОПП 1 . Принципы общения В быстро меняющихся и непредсказуемых условиях чрезвычайных гуманитарных ситуаций медицинские работники испыты- вают сильный стресс вследствие необходимости обследовать как можно больше человек в кратчайшие сроки. Консультации в медицинских учреждениях должны быть краткими, адаптированными и нацеленными на решение самых срочных вопросов. Хорошие коммуникативные навыки помогут медицинским работникам достигнуть этих целей и оказывать эффективную по- мощь взрослым, подросткам и детям с психическими и неврологическими расстройствами, а также расстройствами, связан- ными с употреблением наркотиков и других веществ (ПНВ). » Создайте обстановку, способствующую свободному общению  По возможности примите человека в уединенном месте.  Расположитесь на уровне глаз человека (например, если человек сидит, тоже сядьте).  Поприветствуйте человека; представьтесь и назовите свою должность/роль согласно местным обычаям.  Выразите признательность всем присутствующим.  Спросите человека, хочет ли он, чтобы лица, осуществля- ющие уход, или другие люди остались. X Если это не маленький ребенок, предложите побесе- довать с ним (ней) наедине, если это возможно. Если человек хочет, чтобы другие остались, согласитесь с этим решением. X Если вы общаетесь с человеком наедине, спросите разрешения • задать лицам, осуществляющим уход, вопросы для уточнения их точки зрения и • пригласить лиц, осуществляющих уход, к обсуждению и согласованию плана лечения.  Дайте человеку понять, что информация, обсуждаемая в ходе посещения, будет сохранена в тайне и не будет распространяться без его разрешения, если только вы не обнаружите риск для самого человека или окружающих (имейте в виду, что это сообщение может быть изменено в соответствии с национальными юридическими требо- ваниями к обеспечению конфиденциальности). » Как можно больше вовлекайте человека с расстрой- ством ПНВ в разговор  Даже если перед вами человек с ограниченными возмож- ностями, всегда старайтесь вовлечь его в обсуждение. Это применимо к детям, молодым и пожилым людям с расстройствами ПНВ. Не игнорируйте их, разговаривая только с лицами, осуществляющими уход.  Всегда старайтесь объяснить человеку, что вы делаете (например, во время физикального обследования) и что вы собираетесь сделать. » Сначала выслушайте  Не перебивайте человека с расстройством ПНВ. Люди, подверженные стрессу, не всегда ясно излагают свою историю. В этом случае будьте терпеливы и попросите разъяснить. Не подгоняйте их.  Не вынуждайте человека обсуждать или описывать по- тенциально травмирующие события*, если они не хотят откровенно рассказывать об этом. Просто дайте им знать, что вы готовы выслушать.  Детям может потребоваться больше времени, чтобы осво- иться. Используйте слова, которые им понятны. Установ- ление отношений с детьми может потребовать разгово- ра об их интересах (игрушках, друзьях, школе и пр.). » Выражайтесь ясно и точно  Используйте слова, знакомые человеку. Избегайте специ- альных терминов.  Стресс может нарушать способность людей обрабаты- вать информацию. Излагайте факты по очереди, помогая человеку понять, что было сказано, прежде чем перейти к следующему.  Подведите итог и повторите основные моменты. Возможно, лучше будет попросить человека или лиц, осу- ществляющих уход за ним, записать важные факты. Либо предоставьте человеку список основных моментов. » Ведите себя деликатно, когда люди рассказывают о тяжелом опыте (например, изнасиловании, насилии или самоповреждении)  Заверьте человека, что вы сохраните эту информацию в тайне.  Никогда не преуменьшайте чувств человека, не читайте наставлений и не осуждайте его.  Согласитесь, что человеку может быть трудно рассказы- вать о своей ситуации.  Если требуется направление в другие службы, ясно объ- ясните, что буде происходить на следующих этапах. Полу- чите согласие на передачу сведений другим работникам, которые могут помочь. Например: Общие принципы оказания помощи людям с психическими и неврологическими расстройствами и расстройствами, связанными с употреблением наркотиков и других веществ, в условиях чрезвычайных гуманитарных ситуаций 6О П П 2 . Принципы оценки Клиническая оценка подразумевает выявление расстройства ПНВ, а также определения степени понимания проблем(ы) самим человеком. Кроме этого, важно оценить сильные стороны и имеющиеся ресурсы человека (например, социальную под- держку). Эта дополнительная информация поможет медицинским работникам предложить более качественную помощь. Важно всегда обращать внимание на общий внешний вид, настроение, выражение лица, язык тела и речь человека с расстрой- ством ПНВ во время оценки. » Изучите текущую жалобу  Что привело вас сюда сегодня? Когда и как возникла эта проблема? Что-то изменилось со временем?  Что вы думаете об этой проблеме? Как вы думаете, в чем ее причина?  Как эта проблема влияет на вашу повседневную жизнь? Как проблема влияет на ваши занятия в школе / вашу ра- боту или на повседневную жизнь в местном сообществе?  Что вы делали, чтобы решить эту проблему? Вы пробо- вали принимать какие-либо лекарства? Если да, то какие (например, рецептурные, безрецептурные, раститель- ные)? Какой эффект они дали? » Расспросите человека на предмет семейного анамнеза расстройств ПНВ  Известно ли вам, что у кого-нибудь из родственников была похожая проблема? » Изучите общий анамнез человека  Спросите о любых предыдущих проблемах с физическим здоровьем: X Ранее у вас были серьезные проблемы со здоровьем? X У вас есть какие-либо проблемы со здоровьем, по поводу которых вы сейчас получаете медицинскую помощь?  Спросите, принимает ли человек какие-либо лекарствен- ные средства: X Вы сейчас должны принимать какое-либо лекарство, которое вам назначил врач? X Как называется это лекарство? Оно у вас с собой? Как часто вы его принимаете?  Спросите человека, была ли у него когда-либо аллергиче- ская реакция на лекарственный препарат. » Обсудите текущие стрессовые факторы, стратегии управления стрессом и социальную поддержку  Как изменилась ваша жизнь после... [назовите событие, которое вызвало гуманитарный кризис]?  Вы потеряли близкого человека?  Насколько сильный стресс вы испытываете? Как он на вас воздействует?  Каковы сейчас ваши самые серьезные проблемы?  Как вы справляетесь с этими проблемами или решаете их изо дня в день?  Какую помощь вам оказывают? Вы получаете помощь от членов семьи, друзей или людей из местного сооб- щества? » Расспросите о возможном употреблении алкоголя и наркотиков Вопросы об алкоголе и наркотиках могут быть восприняты болезненно и даже считаться оскорбительными. Однако это важный компонент оценки ПНВ. Объясните человеку, что это часть оценки и постарайтесь задавать вопросы без осуждения и с учетом культурных особенностей.  Мне нужно задать вам несколько стандартных вопросов в рамках этой оценки. Вы употребляете алкоголь (или любое другое вещество, считающееся проблемой в этой области)? [Если да] Сколько в день, в неделю?  Вы принимаете какие-нибудь таблетки, когда испы- тываете стресс, огорчение или страх? Вы принима- ете что-нибудь, чтобы снять боль? Вы принимаете снотворное? [Если да] Сколько вы принимаете в день, в неделю? С какого времени? » Расспросите о возможных суицидальных мыслях и попытках самоубийства Вопросы о самоубийстве также могут считаться оскорби- тельными, но и они – важная часть оценки ПНВ. Постарай- тесь задавать вопросы с учетом культурных особенностей и без осуждения.  Вы можете начать со следующего вопроса: Каковы ваши надежды на будущее? Если человек выражает отчаяние, задайте дополнительные вопросы (см. врезку 1 раздела СУИ), такие как «Как вы думаете, у жизни есть смысл?», «У вас бывают мысли о том, чтобы нанести себе вред?» или «Вы когда-нибудь планировали покончить с жизнью?» (см. раздел СУИ) » Проведите целевое физикальное обследование  Это должно быть направленное физикальное обследова- ние, основанное на информации, полученной во время оценки ПНВ. При выявлении на этом этапе какого-либо соматического заболевания назначьте лечение или на- правьте человека к соответствующим специалистам. X Вы сказали, что ваш сосед сделал вам нечто очень плохое. Я никому об этом не расскажу, но я знаю людей, которые могут вам помочь. Вы не против, если я обсужу то, что с вами случилось, с моим коллегой из организации Х? » Не судите о людях по их поведению  Люди с тяжелыми расстройствами ПНВ могу вести себя необычно. Помните, что это может быть вызвано их забо- леванием. Будьте спокойны и терпеливы. Никогда не смейтесь над человеком. X Если человек ведет себя неподобающим образом (например, возбужден, агрессивен, угрожает вам), найдите источник проблемы и предложите решения. Привлеките лиц, осуществляющих уход, или других сотрудников к созданию спокойной, тихой обста- новки. Если человек крайне подавлен или возбужден, возможно, следует уделить ему первостепенное внимание и сразу начать консультацию. » При необходимости используйте переводчика  При необходимости постарайтесь работать с профессио- нальным переводчиком, желательно того же пола, что и человек с расстройством ПНВ. Если квалифицирован- ный переводчик недоступен, с согласия человека пере- вод могут осуществлять другие медицинские работники или лица, осуществляющие уход.  Если переводит лицо, осуществляющее уход, помните, что человек с расстройством ПНВ может раскрыться не полностью. Кроме того, на общение может повлиять конфликт интересов между человеком и лицом, осущест- вляющим уход за ним. Если возникает такая проблема, пригласите на следующие посещения подходящего переводчика.  Попросите переводчика сохранять конфиденциальность и переводить дословно, не добавляя собственные мысли и толкования. 7О П П » При подозрении на расстройство ПНВ перейдите к соответствующему разделу для оценки. » Если у человека присутствуют признаки нескольких расстройств ПНВ, просмотрите все соответствующие разделы. 3 . Принципы лечения Многие расстройства ПНВ – хронические и требуют длитель- ного контроля и последующего наблюдения. В чрезвычайных ситуациях, однако, может быть сложно обеспечить непрерыв- ность оказания помощи, поскольку людям, которые были или будут перемещены в другую местность, не всегда доступны услуги охраны психического здоровья. Следовательно, важно понять, что лица, осуществляющие уход за людьми с расстрой- ствами ПНВ, представляют собой ценный ресурс. Они могут обеспечить непрерывную помощь, поддержку и контроль во время кризиса. Под лицами, осуществляющими уход, подразу- меваются все, кто разделяет ответственность за благополучие человека с расстройством ПНВ, включая членов семьи, друзей или других доверенных лиц. Лучшее понимание человеком и лицом, осуществляющим уход за ним, расстройства ПНВ, плана лечения и плана последующего наблюдения обеспечит лучшее следование указаниям медицинских работников. » Лечите у людей с расстройствами ПНВ и психические, и соматические заболевания  Предоставьте человеку информацию о заболевании. X Если человек согласен, предоставьте эти сведения и лицу, осуществляющему уход за ним.  Обсудите и определите достижимые цели, составьте и согласуйте с человеком план лечения. X Если человек согласен, пригласите к обсуждению лицо, осуществляющее уход за ним. X Предоставьте следующие сведения о предлагаемом плане лечения: • ожидаемая польза от лечения; • продолжительность лечения; • важность соблюдения указаний врача, в том числе выполнение актуальных психологических вмеша- тельств (например, обучение релаксации) дома, и помощь, которую может оказать в этом отношении лицо, осуществляющее уход; • описание потенциальных побочных эффектов любых прописываемых препаратов; • потенциальное вовлечение социальных работников, кураторов, медицинских работников и других дове- ренных членов местного сообщества (см. «Принци- пы снижения стресса и укрепления социальной поддержки»); • прогноз. Сохраняйте обнадеживающий тон, но да- вайте реалистичный прогноз выздоровления.  Предоставьте сведения о финансовых аспектах плана лечения, если это применимо. » Ответьте на вопросы и опасения относительно плана лечения, которые могут быть у человека и лица, осу- ществляющего уход за ним » Перед уходом человека:  Убедитесь, что человек и лицо, осуществляющее уход за ним, поняли и согласились с планом лечения (например, вы можете попросить их обоих повторить основные пункты плана).  Поощряйте самоконтроль симптомов и расскажите чело- веку и лицу, осуществляющему уход за ним, когда нужно обращаться за неотложной помощью.  Договоритесь о следующем посещении. X Составьте план последующего наблюдения с учетом те- кущей гуманитарной ситуации (например, бегства или перемещения населения и перебоев в оказании услуг). X Если маловероятно, что человек сможет прийти в эту же клинику: • Дайте ему краткий план лечения в письменной фор- ме и попросите брать этот план с собой при посеще- нии любого лечебного учреждения в будущем. • Дайте контактные данные других медицинских учреждений в округе.  Первые посещения для последующего наблюдения должны происходить чаще, пока не появится ответ на лечение.  Когда симптомы начнут ослабевать, рекомендуются более редкие, но регулярные консультации.  Объясните, что при необходимости (например, в случае побочных эффектов препаратов) человек может вер- нуться в клинику в любой момент в промежутке между запланированными посещениями. » На каждой последующей встрече оцените следующее:  Ответ на лечение, побочные эффекты препаратов и соблюдение режима лечения и психосоциальных мер. Отмечайте любой прогресс на пути к намеченным целям и поощряйте следование плану.  Общее состояние здоровья. Регулярно оценивайте физи- ческое здоровье.  Уход за собой (например, питание, личная гигиена, оде- жда) и функционирование в обычной обстановке.  Психосоциальные аспекты и (или) изменения условий проживания, которые могут повлиять на лечение.  Понимание лечения человеком и лицом, осуществляю- щим уход за ним, и их ожидания от лечения. Проясните любые недопонимания.  Всегда проверяйте контактные данные, поскольку они могут часто меняться. » На протяжении всего периода последующего наблюдения:  Поддерживайте регулярную связь с человеком и лицом, осуществляющим уход за ним. По возможности опреде- лите работника или другое доверенное лицо в местном сообществе, которое будет поддерживать связь с челове- ком. Этот человек может быть членом семьи.  Разработайте план действий на случай, если человек не явится на прием. X Постарайтесь выяснить, почему человек не пришел. Работник или другое доверенное лицо в местном сообществе может помочь найти человека (например, прийти к нему домой). X По возможности постарайтесь решить проблему, что- бы человек мог приходить в клинику.  Если состояние человека не улучшается, проконсульти- руйтесь со специалистом. Если женщина беременна или кормит грудью: » Не следует назначать ей препараты, которые могут оказать неблагоприятное воздействие на плод, и обе- спечьте женщине возможность проходить дородовое наблюдение. » Не следует назначать препараты, которые несут потен- циальный риск для ребенка, находящегося на грудном вскармливании. Контролируйте состояние ребенка, полу- чающего грудное молоко женщины, которая принимает какой-либо лекарственный препарат. Рассмотрите воз- можность облегчения доступа в зоны/палатки для детей. 8О П П 4 . Принципы снижения стресса и укрепления социальной поддержки » Определите возможные стрессовые факторы и доступ- ность социальной поддержки  Что вас больше всего беспокоит в эти дни?  Как вы справляетесь с этим беспокойством?  Что дает вам комфорт, силу и энергию?  С кем вам легче всего делиться своими проблемами? Если вам плохо, к кому вы обращаетесь за помощью или советом?  Какие у вас отношения с членами семьи? Как члены вашей семьи и друзья поддерживают вас и почему они заставля- ют вас переживать? » Обращайте внимание на признаки жестокого или пренебрежительного обращения  Обращайте внимание на потенциальные признаки сек- суального или физического насилия (включая бытовое насилие) по отношению к женщинам, детям и пожилым людям (например, необъясненные синяки или травмы, чрезмерный страх, нежелание обсуждать проблемы в присутствии члена семьи).  Обращайте внимание на потенциальные признаки пренебрежительного обращения, в особенности у детей, людей с инвалидностью и пожилых людей (например, не- достаточное питание в семьях с доступом к достаточному количеству еды, слишком замкнувшийся в себе ребенок).  При наличии признаков жестокого или пренебрежитель- ного обращения поговорите с человеком в уединенной обстановке и спросите, причиняет ли кто-нибудь ему вред.  Если вы подозреваете жестокое или пренебрежительное обращение: X немедленно обсудите со своим начальником план действий; X с согласия человека определите ресурсы местного сообщества (например, проверенные юридические службы и защитные организации), которые можно использовать для защиты. » На основе собранной информации рассмотрите следующие стратегии:  Решение проблемы: X используйте методики решения проблем*, чтобы по- мочь человеку воздействовать на основные стрессовые факторы. Если источники стресса невозможно устра- нить или уменьшить, можно использовать те же методи- ки, чтобы выявить способы справиться со стрессовым фактором. В целом, не давайте прямых советов. Попро- буйте помочь человеку найти собственные решения. X Работая с детьми и подростками, необходимо оценить и принять меры по отношению к источникам стресса лица, осуществляющего уход.  Окажите дополнительную социальную поддержку: X Помогите человеку выбрать поддерживающих его и надежных членов семьи, друзей и членов местного сообщества и подумать, какую помощь может оказать каждый из них. X С согласия человека направьте его туда, где могут быть использованы другие ресурсы местного сообще- ства для социальной поддержки. Социальные работ- ники, кураторы и другие доверенные члены местного сообщества могут помочь человеку получить доступ к таким ресурсами, например: • службе социальной помощи или защиты; • убежищу, пищевым продуктам и другим вещам; • центрам, группам взаимопомощи и поддержки в местном сообществе; • деятельности, приносящей доход, и другой профес- сиональной деятельности; • формальному/неформальному образованию; • зонам для детей или другим организованным занятиям для детей и подростков. Направляя человека куда-либо, помогите ему полу- чить доступ к этой услуге (например, дайте указания, как туда добраться, сообщите часы работы, номер те- лефона и пр.) и дайте человеку краткое направление.  Научите справляться со стрессом: X найдите и разработайте положительные способы рас- слабления (например, прослушивание музыкальных произведений, спортивные игры и пр.); X обучите человека и лиц, осуществляющих уход за ним, методикам уменьшения стресса (например, дыхатель- ным упражнениям (см. врезку ОПП 2). • В некоторых ситуациях вы можете направить людей к медицинскому работнику (например, медсестре или психосоциальному работнику), которые могут научить этим методикам. » Способствуйте снижению стресса у лиц, осуществляю- щих уход  Спросите у лиц, осуществляющих уход, о следующем: X тревогах и беспокойстве, связанных с уходом за чело- веком с расстройством ПНВ, в текущей чрезвычайной гуманитарной ситуации; X практических трудностях (например, нехватка време- ни, свободы, денег); X возможности заниматься другими повседневными де- лами, такими как работа или участие в жизни местного сообщества; X физической усталости; X доступной им социальной поддержке: • Есть ли другие люди, которые могут помочь вам, когда вы не можете ухаживать за человеком (например, когда вы больны или очень устали); X психологическом благополучии. Если вам кажется, что лицо, осуществляющее уход, испытывает острый стресс или его состояние нестабильно, оцените его на предмет наличия расстройства ПНВ (например, см. раздел ДЕП, ВЕЩ).  После оценки постарайтесь удовлетворить потребности и устранить тревоги лица, осуществляющего уход. Для этого вы можете: X предоставить информацию; X помочь человеку, осуществляющему уход, связаться с соответствующими службами и источниками под- держки в местном сообществе; X обсудить временный уход. Другой член семьи или подходящий человек может временно взять уход на себя, пока основное лицо, осуществляющее уход, отдыхает или занимается другими важными делами; X провести консультирование по решению проблем* и научить справляться со стрессом; X назначить лечение любого расстройства ПНВ, диагно- стированного у лица, осуществляющего уход.  Отметьте, что тяжело ухаживать за людьми с расстрой- ствами ПНВ, но скажите, что важно продолжать этот уход. Даже если это сложно, следует с уважением относиться к подопечному и как можно больше привлекать его к принятию решений о его собственной жизни. Снижение стресса и укрепление социальной поддержки – неотъемлемая часть лечения ПНВ в чрезвычайных гуманитарных ситуациях, когда люди часто испытывают крайне сильный стресс. Имеется в виду стресс, испытываемый не только людьми с расстройствами ПНВ, но и лицами, осуществляющими уход за ними, и людьми, зависящими от них. Стресс часто способствует развитию расстройств ПНВ или обостряет их. Социальная поддержка может смягчить многие неблагоприятные последствия стресса, поэтому важно уделять ей должное внимание. Укрепление социальной поддержки – также обязательный компонент защиты (см. «Принципы защиты прав человека») и обеспечения общего благополучия населения, страдающего от гумани- тарного кризиса (см. «Принципы повышения общего благополучия»). Врезка ОПП 1. Укрепление поддержки на уровне местного сообщества Помимо клинического лечения поощряйте занятия, которые улучшают поддержку в семье и местном сообще- стве каждого, в особенности маргинализованных членов сообщества. Подробные руководящие принципы см. в документе «Основные сведения о защите на базе местного сообщества» (УВКБ ООН, 2013 г.) и Плане меро- приятий 5.2 «Руководящих принципов МПК по охране психического здоровья и психосоциальной поддержке в чрезвычайных ситуациях» (МПК, 2007 г.). Врезка ОПП 2. Упражнение на релаксацию: инструкции по обучению медленному дыханию Я хочу научить вас, как дышать так, чтобы помочь вашему телу и разуму расслабиться. Нужно потренироваться, прежде чем вы почувствуете всю пользу этой методики. Эта стратегия основана на дыхании, поскольку во время стресса наше дыхание становится быстрым и поверхност- ным, что увеличивает напряжение. Чтобы расслабиться, нужно изменить дыхание. Сначала давайте расслабим тело. Слегка встряхните и расслабьте руки и ноги. Пусть они станут свободными и вялы- ми. Отведите плечи назад и поводите головой из стороны в сторону. Теперь положите одну руку на живот, а другую – на верхнюю часть груди. Представьте, что у вас в животе воздушный шар, который надувается, когда вы вдыхаете, так что ваш живот расширяется. Когда вы выдыхаете, из воздушного шара тоже выходит воздух, так что ваш живот сдувается. Посмотрите на меня. Сначала я выдохну весь воздух из живота. [Покажите дыхание животом, при этом постарайтесь демонстративно выпячивать и втягивать живот.] Теперь дышите животом вместе со мной. Помните, сперва мы выдыхаем, пока не выйдет весь воздух; после этого вдыхаем. Если можете, постарайтесь вдыхать через нос и выдыхать через рот. Отлично! Второй шаг – замедление дыхания. Мы будем вдыхать в течение трех секунд, задерживать дыхание на две секунды и выдыхать в течение трех секунд. Я буду считать вместе с вами. Вы можете закрыть глаза или оставить их открытыми. Итак, вдыхаем, 1, 2, 3. Задерживаем дыхание, 1, 2. Выдыхаем, 1, 2, 3. Заметили, как медленно я считаю? [Повторяйте это дыхательное упражнение не менее одной минуты.] Замечательно. Когда будете заниматься самостоятельно, не обязательно укладываться в три секунды. Просто постарайтесь замедлить дыхание, когда испытываете стресс. Хорошо, теперь выполняйте упражнение самостоятельно в течение одной минуты. 9 О П П 10 О П П 5 . Принципы защиты прав человека Люди с тяжелыми расстройствами ПНВ нуждаются в защите, поскольку подвергаются большему риску нарушения прав человека. Они часто испытывают трудности в уходе за собой и членами семьи, помимо дискриминации во многих областях, включая работу, жилищное обустройство и семейную жизнь. У них может быть плохой доступ к гуманитарной помощи. С ними могут жестоко или пренебрежительно обращаться в семье, и они часто не имеют возможности полноценно участвовать в жизни местного сообщества. Некоторые люди с тяжелыми расстройствами ПНВ могут не осознавать, что у них есть проблема, которая требует медицинской помощи и поддержки. Во время чрезвычайных гуманитарных ситуаций могут иметь место нарушения прав людей с расстройствами ПНВ, в том числе: » ограничение в правах на удовлетворение основных потребностей для выживания, таких как еда, вода, средства гигиены, убежище, медицинская помощь, защита и поддержка существования. » отказ в праве на реализацию правоспособности; » отказ в доступе к услугам для удовлетворения их особых потребностей; » физическое и сексуальное насилие, эксплуатация, жестокое и пренебрежительное обращение и незаконное содержание под стражей; » отсутствие должного внимания или разлука с семьей во время перемещения в другую местность; » отсутствие должного внимания и пренебрежительное отношение в специализированных учреждениях. К сожалению, защитные организации и программы помощи инвалидам в местном сообществе не всегда включают, а иногда и активно исключают из своей сферы деятельности защиту людей с тяжелыми расстройствами ПНВ. Следовательно, медицин- ские работники могут активно выступать в поддержку и устранять пробел в защите этих людей. Ниже перечислены основные действия с целью защиты людей с расстройствами ПНВ, живущих в местном сообществе в чрез- вычайных гуманитарных ситуациях. » Вовлекайте заинтересованные стороны  Выявите заинтересованные стороны, которых следует уведомить о вопросах защиты людей с расстройствами ПНВ. К заинтересованным сторонам относятся: X люди с расстройствами ПНВ и лица, осуществляющие уход за ними; X лидеры местного сообщества (например, выборные представители сообщества, старейшины, учителя, религиозные лидеры, народные и духовные целители); X руководители различных служб (например, служб защиты/безопасности, здравоохранения, служб, предоставляющих убежище, воду, питание, службы санитарного контроля, службы образования, програм- мы обеспечения жильем); X руководители служб по работе с инвалидами (многие такие службы неумышленно не обращают внимание на инвалидность вследствие расстройств ПНВ); X представители групп местного сообщества (группы молодежи или женщин) и организации по защите прав человека; X полиция и правовые органы.  Организуйте ознакомительные мероприятия для заинте- ресованных сторон: X Рассмотрите возможность проведения ознакомитель- ных семинаров о расстройствах ПНВ. X Обсудите формат и реализацию ознакомительных мероприятий с людьми с расстройствами ПНВ, лица- ми, осуществляющими уход за ними, с социальными службами и службами по работе с инвалидами. X Во время ознакомительных мероприятий: • предоставьте сведения и проясните заблуждения относительно людей с расстройствами ПНВ; • расскажите о правах людей с расстройствами ПНВ, в том числе о праве на равный доступ к гуманитар- ной помощи и защите; • поговорите о дискриминации людей с расстрой- ствами ПНВ; • призовите к поддержке тех, кто осуществляет уход за людьми с расстройствами ПНВ. » Защищайте права людей с тяжелыми расстройствами ПНВ в медицинских учреждениях  Всегда уважительно относитесь к людям с расстройства- ми ПНВ.  Убедитесь, что у людей с расстройствами ПНВ доступ к медицинской помощи такой же, как и у людей без таких расстройств.  Уважайте право человека отказаться от медицинской помощи, если он дееспособен для принятия такого реше- ния (см. подписанные международные конвенции).  Не поощряйте помещение людей в специализированные учреждения. Если человек уже находится в специализи- рованном учреждении, призовите к защите его прав в этом учреждении. » Поощряйте интеграцию людей с тяжелыми расстрой- ствами ПНВ в местное сообщество  Призывайте к включению людей с расстройствами ПНВ в программы обеспечения жильем, защиты и в другие мероприятия в местном сообществе.  Призывайте к принятию детей с эпилепсией и другими расстройствами ПНВ в общеобразовательные учреж- дения.  Призывайте к включению программ для детей и взрос- лых с умственной отсталостью / задержкой развития в местные программы по оказанию поддержки инвалидам.  Призывайте к поддержанию, насколько это возможно, ав- тономии и независимости людей с расстройствами ПНВ. Общие принципы защиты в рамках гуманитарной деятельности описаны в справочнике «Сфера» (Sphere Project, 2011 г.). Дополнительные указания по защите людей в психиатрических больницах / специализированных учреждени- ях см. в Плане мероприятий 6.3 «Руководящих принципов МПК по охране психического здоровья и психосоциаль- ной поддержке в чрезвычайных ситуациях» (МПК, 2007 г.). 11 О П П 6 . Принципы заботы об общем благополучии Помимо клинической помощи, люди с расстройствами ПНВ нуждаются в других видах поддержки для обеспечения их общего благополучия. Это особенно важно в чрезвычайных гуманитарных ситуациях, когда часто нарушается работа основных служб и социальных структур, под угрозой семейная жизнь и безопасность. Люди с расстройствами ПНВ сталкиваются с допол- нительными трудностями в выполнении повседневных дел и осуществлении основного ухода за собой. Роль медицинских работников выходит за рамки клинической работы и включает отстаивание права на общее благополучие людей с расстрой- ствами ПНВ в различных секторах, как показано в пирамиде Руководящих принципов МПК (см. рисунок ОПП 1). » Помогайте людям с расстройствами ПНВ получить безо- пасный доступ к услугам, необходимым для выживания и достойного существования (например, вода, средства гигиены, пищевые продукты, убежище, обеспечение жизнедеятельности). Для этого вы можете:  проинформировать о наличии и местонахождении таких услуг;  активно направлять пациентов и работать с социальным сектором, чтобы помочь людям связаться с социальными службами (например, курирование пациента социаль- ным работником).  проинформировать о мерах безопасности, если человек не полностью осознает угрозы его безопасности. » Обеспечьте людям с расстройствами ПНВ приоритет- ный доступ к соответствующим занятиям, например, помогите детям с такими расстройствами попасть в детские зоны. » Поддерживайте общее физическое здоровье людей с расстройствами ПНВ:  Организуйте регулярные медицинские осмотры и вакцинацию.  Дайте рекомендации относительно основного ухода за собой (питание, физическая активность, безопасный секс, планирование семьи и пр.). Клини- ческие услуги Узконаправленная психосоциальная поддержка Укрепление поддержки на уровне местного сообщества и семьи Оказание основных услуг и обеспечение безопасности Примеры: Охрана психического здоровья в клинике (сотрудниками специализированной клиники или специализированными медицинскими работниками) Базовая эмоциональная и практическая поддержка отдельных людей и семей Активация социальных структур Поддерживающие зоны для детей Призыв к соблюдению правил оказания гуманитарной помощи: основные услуги оказываются достойно, с соблюдением мер безопасности и приемлемы в социальном отношении Рисунок ОПП 1. Пирамида мер, направленных на поддержание психического здоровья и психосоциальной поддержки МПК (приведено с разрешения)

» Значимые симптомы острого стрессового расстройства (ОСР) . Люди с этими симптомами могут описывать их в форме различных неспецифических психологических жалоб и жалоб на не объяснимые физическим состоянием соматические симптомы. Эти симптомы включают реакции в течение ме- сяца после потенциально травмирующего события, по причине которых люди обращаются за помощью или которые значительно мешают повседневным занятиям, а также не соответствуют критериям других расстройств, рассматрива- емых в настоящем руководстве. В настоящем разделе описаны оценка и лечение значимых симптомов острого стрессового расстройства. » Посттравматическое стрессовое расстройство (см . раздел ПТСР) . Если характерный комплекс симптомов (повторное переживание, избегание и повышенное чувство опасности) сохраняет- ся более месяца после потенциально травмирующего события и существенно мешает повседневным занятиям, у человека могло развиться посттравматическое стрессовое расстройство. » Проблемы и расстройства, которые более вероятны после воздействия стрессового фактора (например, потенциально травмирующего события), но которые могли также возникнуть в отсутствие такого воздействия . К ним относятся: депрессивное расстройство средней или тяжелой степени (см. раздел ДЕП), психоз (см. раздел ПСИ), пагубное употребление алкоголя и наркотических средств (см. раздел ВЕЩ), суицид (см. раздел СУИ) и прочие значимые жалобы, связанные с психическим здоровьем (см. раздел ПРОЧ). » Реакции, не являющиеся клинически значимыми и не требующие клинического лечения . Из всех реакций эти наиболее распространены. К ним относятся преходящие реакции, по поводу которых люди не обра- щаются за помощью и которые не мешают повседневным занятиям. В этих случаях медицинский работник должен оказать поддержку, помочь удовлетворить потребности и снять опасения человека, а также отследить, пройдет ли эта реакция сама собой. 13 О СР Острое Стрессовое Расстройство ОСР В чрезвычайных гуманитарных ситуациях взрослые, подростки и дети часто переживают потенциально травмирующие события* . Такие события запускают множество эмоциональ- ных, когнитивных, поведенческих и соматических реакций . Хотя большинство реакций но- сят самоограничивающийся характер и не перерастают в психическое расстройство, люди с тяжелыми реакциями могут обращаться за помощью в медицинские учреждения . Во многих чрезвычайных гуманитарных ситуациях люди страдают от различных сочетаний потенциально травмирующих событий и утрат, поэтому они могут страдать одновременно от острого стрессового расстройства и горя . Симптомы, оценка и лечение острого стрес- сового расстройства и горя во многом сходны, однако горе рассматривается в отдельном разделе (см. раздел ГОРЕ) . После недавнего потенциально травмирующего события врач должен уметь определить следующее: 14 О СР Вопрос 1 для оценки состояния: было ли недавно в жизни человека потенциально травмирующее событие? » Спросите, было ли недавно в жизни человека потенциально травмирующее событие. Потенциально травмирующее событие – любое устрашающее или пугающее событие, на- пример физическое или сексуальное насилие (в том числе домашнее насилие), присутствие при актах жестокости, крупные аварии или травмы. Вы можете задать следующие вопросы:  Какой крупный стресс вы перенесли? Ваша жизнь была в опасности? Вы испытали нечто очень страшное или ужасающее или чувствовали себя очень плохо? Дома вы ощущаете себя в безопасности? » Спросите, сколько времени прошло после события(й). » Перейдите к вопросу 2 для оценки состояния, если потен- циально травмирующее событие произошло в течение последнего месяца. » Если произошла тяжелая утрата (например, смерть любимо- го человека), также оцените состояние на предмет наличия проявлений горя (см. раздел ГОРЕ). » Если потенциально травмирующее событие произошло более чем 1 месяц назад, рассмотрите другие расстройства, описанные в настоящем руководстве (см. разделы ДЕП, ПТСР, ПСИ, ВЕЩ). Вопрос  2 для оценки состояния: если потенциально травмирующее событие произошло в течение последнего месяца, есть ли у человека значимые симпто- мы острого стрессового расстройства? » Проверьте наличие:  беспокойства по поводу угроз, связанных с травмирую- щим(-и) событием(-ями);  нарушений сна;  трудностей с концентрацией внимания;  повторяющихся кошмарных снов, ярких повторных пе- реживаний* или навязчивых воспоминаний* о событиях, сопровождающихся сильным страхом или ужасом;  сознательного избегания мыслей, воспоминаний, заня- тий или ситуаций, напоминающих человеку о событиях (например, избегание разговоров на темы, которые вызывают воспоминания, или избегание посещения мест, где произошли события);  состояния нервозности или «на взводе»: чрезмерного беспокойства и ожидания опасности либо сильной реак- ции на громкие звуки или неожиданные движения; шокированности, ошеломления или оцепенения либо неспособности чувствовать что-либо;  любых беспокоящих эмоций (например, частая плакси- вость, гнев) или мыслей;  изменений поведения, таких как: X агрессия; X изоляция или самоизоляция от общества; X рискованные действия у подростков; X утрата приобретенных навыков*, например ночное недержание мочи, повышенная эмоциональная зави- симость или плаксивость у детей  гипервентиляции (т. е. быстрое дыхание, одышка);  не объяснимых физическим состоянием соматических симптомов, таких как: X сердцебиение, головокружение; X головные боли, генерализованная боль; X диссоциативные симптомы, связанные с телом (напри- мер, паралич, не объяснимый физическим состоянием*, неспособность видеть или слышать, псевдоприпадки*). » Значимые симптомы острого стрессового расстройства вероятны, если ситуация соответствует всем следующим критериям:  потенциально травмирующее событие произошло примерно в течение последнего месяца;  симптомы возникли после события;  симптомы существенно мешают повседневным заняти- ям или человек обратился за помощью по поводу этих симптомов. Вопрос 3 для оценки состояния: имеется ли сопутствующее расстройство? » Оцените состояние на предмет наличия любых соматиче- ских расстройств, которые могут объяснить симптомы, и при необходимости назначьте лечение. » Оцените состояние на предмет наличия любого другого психического или неврологического расстройства или расстройства, связанного с употреблением наркотиков и других веществ (ПНВ) (включая депрессию), которое описано в настоящем руководстве и может объяснить симптомы; при необходимости назначьте лечение. 15 О СР 3 Описанный здесь подход часто называют первой психологической помощью (ППП), если он применяется по отношению к первым последствиям чрезвычайного стрессового события (см. ВОЗ, WTF и WVI, 2013 г.). НЕ назначайте препараты для лечения симптомов острого стрессового расстройства (если далее не указано иное). » Окажите базовую психосоциальную поддержку3 Внимательно выслушайте. НЕ вынуждайте человека говорить. Спросите человека о его нуждах и опасениях. Помогите человеку удовлетворить основные потребно- сти, получить доступ к услугам, связаться с семьей и получить другую социальную поддержку.  Защитите человека от причинения (дальнейшего) вреда. » Предложите дополнительную психосоциальную поддержку, как описано в разделе «Принципы снижения стресса и укрепления социальной поддержки» (см. раздел «Общие принципы оказания помощи»):  Воздействуйте на психосоциальные факторы, вызыва- ющие у человека стресс в настоящий момент. Окажите дополнительную социальную поддержку. Научите человека, как справляться со стрессом. » Расскажите человеку о нормальных реакциях на горе и острое стрессовое расстройство, например: Люди часто испытывают такие реакции после подобных событий.  В большинстве случаев реакции проходят со временем. » Назначьте лечение сопутствующих заболеваний. 2 . Если острое стрессовое расстройство проявляется нарушением сна, предложите следующее дополнительное лечение: » Объясните, что у людей, переживших сильный стресс, часто возникают проблемы со сном (бессонница). » Выявите и воздействуйте на любые причины бессонницы в окружающей среде (например, шум). » Выявите и воздействуйте на любые соматические причины бессонницы (например, физическая боль). » Расскажите о правилах здорового сна, в том числе о соблю- дении режима сна (например, ложиться спать и вставать в одно и то же время), избегании употребления кофе, нико- тина и алкоголя вечером или перед сном. Подчеркните, что алкоголь нарушает сон. » В исключительных, крайне тяжелых случаях, когда психоло- гические меры (например, методики релаксации) неосу- ществимы или неэффективны, а бессонница существенно мешает повседневным занятиям, можно рассмотреть краткосрочное (3–7 дней) лечение бензодиазепинами). Доза: X Взрослым назначайте 2–5 мг диазепама перед сном. X Пожилым людям назначайте 1–2,5 мг диазепама перед сном. X Перед назначением диазепама проверьте возможные лекарственные взаимодействия. X Частые побочные эффекты безнодиазепинов включа- ют сонливость и мышечную слабость. X Внимание: бензодиазепины могут замедлять дыхание. Может потребоваться регулярный контроль состояния. X Внимание: бензодиазепины могут вызывать зави- симость*. Используйте только для краткосрочного лечения. Примечание: X Это лечение – только для взрослых. X Не назначайте бензодиазепины детям или подросткам. X Не следует назначать этот препарат беременным или кормящим женщинам. X При назначении этого препарата пожилым людям часто проверяйте их состояние на предмет побочных эффектов. X Это временное решение крайне тяжелого наруше- ния сна. X Бензодиазепины не следует использовать для лечения бессонницы у взрослых или детей, вызванной тяжелой утратой. X Бензодиазепины не следует использовать для лечения любых других симптомов острого стрессового рас- стройства или ПТСР. 1 . Во ВСЕХ случаях: 16 О СР » Расспросите о появлении ночного недержания мочи, чтобы убедиться, что оно началось после стрессового события. Исключите и устраните другие возможные причины (например, инфекцию мочевых путей). » Объясните следующее: Ночное недержание мочи – распространенная неопас- ная реакция у детей, переживших стресс. Детей не следует наказывать за ночное недержание мочи, поскольку наказание усиливает стресс ребенка и может усугубить проблему. Лицу, осуществляющему уход, не следует стыдить ребенка, упоминая ночное недержание мочи при других людях. Лицу, осуществляющему уход, следует сохранять спокой- ствие и эмоциональную поддержку. » Рассмотрите возможность обучения лиц, осуществляющих уход, простым поведенческим методам (например, поощ- рение ограниченного употребления жидкостей перед сном, поощрение использования туалета перед сном, поощрение в случае пробуждения в сухой постели). Наградой может быть все, что нравится ребенку: дополнительное игровое время, звездочки на схеме или другое похожее поощрение, приемлемое в местных условиях. 3 . Если у ребенка острое стрессовое расстройство проявляется ночным недержанием мочи, предложите следующее дополнительное лечение: 4 . Если острое стрессовое расстройство проявляется гипервентиляцией (слишком частые и неконтролируемые дыхательные движения), предложите следующее дополнительное лечение: » Исключите и устраните другие возможные причины, даже если гипервентиляция началась сразу после стрессо- вого события. Всегда проводите необходимое медицинское обследование для выявления возможных соматических причин, таких как заболевание легких. » Если никаких соматических причин не выявлено, заверьте человека, что гипервентиляция иногда возникает после сильного стресса и маловероятно, что это серьезная меди- цинская проблема. » Сохраняйте спокойствие и по возможности устраните по- тенциальные источники беспокойства. Помогите человеку восстановить нормальное дыхание с помощью методики медленного дыхания (см. «Принципы снижения стресса и укрепления социальной поддержки» в разделе «Общие принципы оказания помощи») (не рекомендуйте дышать в бумажный пакет). 5 . Если острое стрессовое расстройство проявляется диссоциативными симптомами, связанными с телом, (например, паралич, не объяснимый физическим состоянием, неспособность видеть или слышать, псевдоприпадки), предложите следующее дополнительное лечение: » Исключите и устраните другие возможные причины, даже если симптомы начались сразу после стрессового события. Всегда проводите необходимое медицинское обследование для выявления возможных соматических причин. В разделе по эпилепсии приведены руководящие принципы медицинских вмешательств при судорогах / припадках (см. раздел ЭПИ). » Признайте страдания человека и сохраняйте уважительное отношение к нему. Избегайте упоминания любых выгод, которые человек может получить благодаря симптомам. » Попросите человека самого объяснить симптомы и при- мените общие руководящие принципы лечения не объяс- нимых физическим состоянием соматических симптомов (см. раздел ПРОЧ). » Заверьте человека, что эти симптомы иногда возникают после сильного стресса и маловероятно, что это серьезная медицинская проблема. » Рассмотрите возможность, с учетом культурных особенно- стей, применения вмешательств, которые не причиняют вреда. 6 . Попросите человека вернуться в течение 2–4 недель, если симптомы не ослабли, или в любое время, если симптомы усугубятся . 17 ГО РЕ Горе ГОРЕ В чрезвычайных гуманитарных ситуациях взрослые, подростки и дети часто переживают тяжелые утраты . Горе – эмоциональное страдание людей после утраты . Хотя большинство реакций на утрату носят самоограничивающийся характер и не перерастают в психическое расстройство, люди со значимыми симптомами горя чаще обращаются за помощью в меди- цинские учреждения . После утраты врач должен уметь определить следующее: » Значимые симптомы горя (ГОРЕ) . Как и при симптомах острого стрессового расстройства, люди, переживающие утрату, могут описывать различные неспеци- фические психологические жалобы и жалобы на не объяснимые физическим состоянием соматические симптомы. Симпто- мы горя после утраты считаются значимыми, если они существенно мешают повседневным занятиям (выходят за пределы, принятые местными обычаями) или если человек обращается за помощью по поводу этих симптомов. В настоящем разде- ле описаны оценка и лечение значимых симптомов горя. » Пролонгированная реакция горя . Если значимые симптомы горя сохраняются на протяжении длительного периода времени, это может быть пролонгированная реакция горя. Это состояние подразумевает серьезную озабоченность или сильное стремление к умершему, сопровождаю- щееся сильным эмоциональным страданием и существенными трудностями в выполнении повседневных занятий в течение как минимум последних 6 месяцев (и в течение периода, значительно превышающего принятый местными обычаями). В этих случаях медицинскому работнику следует проконсультироваться со специалистом. » Проблемы и расстройства, которые более вероятны после воздействия стрессового фактора (например, утраты близкого человека), но которые могут возникнуть и в отсутствие такого воздействия . Сюда относятся: депрессивное расстройство средней или тяжелой степени (см. раздел ДЕП), психоз (см. раздел ПСИ), пагубное употребление алкоголя и наркотических средств (см. раздел ВЕЩ), самоповреждение или суицид (см. раздел СУИ) и прочие значимые жалобы, связанные с психическим здоровьем (см. раздел ПРОЧ). » Реакции, не являющиеся клинически значимыми и не требующие клинического лечения . Из всех реакций эти наиболее распространены. К ним относятся преходящие реакции, по поводу которых люди не обраща- ются за помощью и которые не мешают повседневным занятиям в рамках, принятых местными обычаями. В этих случаях медицинский работник должен оказать поддержку, помочь удовлетворить потребности и снять опасения человека, а также отследить, пройдет ли эта реакция сама собой; однако такие реакции не требуют клинического лечения. 18 ГО РЕ Вопрос 1 для оценки состояния: человек недавно перенес тяжелую утрату? 4 Этот период может превышать 6 месяцев в культурах, где принято горевать по умершему больше 6 месяцев. » Спросите, перенес ли человек недавно тяжелую утрату. Вы можете задать следующие вопросы:  Как катастрофа/конфликт на вас повлияли?  Вы потеряли друга или члена семьи? Ваш дом? Ваши день- ги? Вашу работу или средства к существованию? Ваше местное сообщество?  Как повлияла на вас эта утрата?  Кто-нибудь из членов вашей семьи или друзей числится пропавшим? » Спросите, сколько времени прошло после события(й). » Перейдите к вопросу 2, если тяжелая утрата произошла в течение последних 6 месяцев. » Если тяжелая утрата произошла более чем 6 месяцев назад, рассмотрите другие расстройства, описанные в настоящем руководстве (см. разделы ДЕП, ПТСР, ПСИ, ВЕЩ), или про- лонгированную реакцию горя. Вопрос 2 для оценки состояния: если тяжелая утрата произошла в течение по- следних 6 месяцев4, человек испытывает значимые симптомы горя? » Проверьте наличие:  грусти, тревожности, гнева, отчаяния;  тоски и озабоченности утратой;  навязчивых воспоминаний*, образов или мыслей о покойном  потери аппетита;  потери энергии;  нарушений сна;  трудностей с концентрацией;  изоляция или самоизоляция от общества;  не объяснимых физическим состоянием соматических симптомов (например, аритмии, головной боли, генера- лизованной боли);  допускаемых местной культурой реакций на горе (на- пример, человек слышит голос покойного, покойный приходит к нему во сне). » Значимые симптомы горя вероятны, если ситуация соот- ветствует всем следующим критериям:  одна или более утрат за последние примерно 6 месяцев;  после утраты возник любой из вышеперечисленных симптомов;  симптомы мешает повседневным занятиям (выходят за рамки, допускаемые местной культурой) или человек обратился за помощью по поводу этих симптомов. Вопрос 3 для оценки состояния: имеется ли сопутствующее расстройство? » Проверьте состояние на предмет наличия любых сомати- ческих расстройств, которые могут объяснить симптомы, и при необходимости назначьте лечение. » Проверьте состояние на предмет наличия любого другого психического или неврологического расстройства или расстройства, связанного с употреблением наркотиков и других веществ (ПНВ) (включая депрессию), которое описано в настоящем руководстве и может объяснить сим- птомы; при необходимости назначьте лечение. 19 ГО РЕ 5 Описанный здесь подход часто называют первой психологической помощью (ППП), если он применяется по отношению к первым последствиям чрезвычайного стрессового события (см. ВОЗ, WTF и WVI, 2013 г.). НЕ назначайте препараты для лечения симптомов горя . 1 . Окажите базовую психосоциальную поддержку5 » Внимательно выслушайте. НЕ вынуждайте человека говорить. » Спросите человека о его нуждах и опасениях. » Помогите человеку удовлетворить основные потребности, получить доступ к услугам, связаться с семьей и получить другую социальную поддержку. » Защитите человека от причинения (дальнейшего) вреда. 2 . Предложите дополнительную психосоциальную поддержку, как описано в «Принципах снижения стресса и укрепления социальной поддержки» (см . раздел «Общие принципы оказания помощи»): » Воздействуйте на психосоциальные факторы, вызываю- щие у человека стресс в настоящий момент. » Оказывайте дополнительную социальную поддержку. » Научите человека, как справляться со стрессом. 3 . Расскажите человеку о распространенных реакциях на утрату, например: » Люди могут по-разному реагировать на тяжелую утрату. У одних это вызывает сильные чувства, у других – нет. » Слезы – не признак слабости. » Люди, которые не плачут, могут эмоционально стра- дать также сильно, но выражать это страдание другими способами. » Вам может казаться, что грусть и боль, которые вы испы- тываете, никогда не пройдут, но в большинстве случаев эти чувства притупляются со временем. » Иногда человек может некоторое время чувствовать себя нормально, но затем что-то напомнит ему об утрате, и он испытает те же чувства, что и в начале. Это нор- мально. Опять же, эти ощущения со временем станут слабее и реже. » Не бывает правильного переживания горя. Иногда вам может быть очень грустно, а в другое время вы можете получать удовольствие от жизни. Не критикуйте себя за то, что чувствуете в данный момент. 4 . Назначьте лечение сопутствующих заболеваний . 5 . Обсудите и помогите реализовать допустимые местными обычаями способы приспособления / скорби* » Спросите, были ли проведены или запланированы соответ- ствующие траурные церемонии / обряды. Если это невоз- можно, обсудите препятствия и способы их преодоления. » Постарайтесь узнать, где находится тело. Если тело пропа- ло, помогите найти его или опознать останки. » Если тело невозможно найти, обсудите альтернативные способы сохранить воспоминания, например создание мемориала. 6 . Если это осуществимо и допустимо местной культурой, поощряйте скорей- ший возврат к прошлым нормальным занятиям (например, в школе или на работе, дома или в местном сообществе) . 7 . Специфическое лечение нарушений сна, ночного недержания мочи, гипер- вентиляции и диссоциативных симптомов после недавней утраты описаны в разделе, посвященном острому стрессовому расстройству (см . раздел ОСР) . 20 ГО РЕ 6 Этот период может превышать 6 месяцев в культурах, где принято горевать по умершему больше 6 месяцев. 8 . Если перед вами маленький ребенок: » Ответьте на вопросы ребенка, давая ясные и правдивые объяснения в соответствии с уровнем его развития. Не лги- те в ответ на вопрос об утрате (например, «Где моя мама?»). Это создаст путаницу и может подорвать доверие человека к медицинскому работнику. » Проверьте на предмет «магического мышления», часто встречающегося у детей младшего возраста, и скорректи- руйте его (например, дети могут думать, что они в ответе за утрату; также они могут думать, что любимый человек умер, потому что они плохо себя вели или огорчили его). 9 . Обеспечьте детям, подросткам и другим уязвимым людям, потерявшим родителей или других опекунов, защиту и постоянный поддерживающий уход, в том числе социоэмоциональную поддержку . » При необходимости свяжите человека с надежными защит- ными организациями/сетями. 10 . Если подозревается пролонгированная реакция горя, проконсультируй- тесь со специалистом для дальнейшей оценки и лечения . » У человека может быть пролонгированная реакция горя, если симптомы тяжелой утраты включают серьезную озабоченность или сильное стремление к умершему, со- провождающиеся сильным эмоциональным страданием и существенными трудностями в выполнении повседневных занятий в течение как минимум последних 6 месяцев.6 11 . Попросите человека вернуться в течение 2–4 недель, если симптомы не ослабли, или в любое время, если симптомы усугубятся . 21 Д ЕП Депрессивное расстройство средней или тяжелой степени ДЕП Депрессивное расстройство средней или тяжелой степени может развиваться у взрослых, подростков и детей без воздействия какого-либо конкретного стрессового фактора . В любом сообществе есть люди, страдающие депрессивным расстройством средней или тяжелой степени . Однако значимые утраты и стресс во время чрезвычайных гуманитарных ситуаций могут вызывать горе, чувство страха, вины, стыда и безнадежности, повышая риск развития депрессивного расстройства средней или тяжелой степени . Тем не менее, эти эмоции также могут быть нормальной реакцией на недавно перенесенное несчастье . Лечение депрессивного расстройства средней или тяжелой степени следует рассматри- вать, если симптомы сохраняются на протяжении нескольких недель и существенно меша- ют повседневным занятиям . » » » » 22 Д ЕП 7 Это описание депрессивного эпизода средней или тяжелой степени согласуется с текущим проектом МКБ-11. Вопрос 1 для оценки состояния: у человека есть депрессивное расстройство средней или тяжелой степени?7 » Оцените следующее: A . У человека имеется хотя бы один из следующих основ- ных симптомов депрессивного расстройства в течение менее 2 недель: Устойчивое подавленное настроение X У детей и подростков: раздражительность или пода- вленное настроение Выраженное снижение интереса и способности полу- чать удовольствие от различных занятий, включая те, которые ранее приносили удовольствие X Последнее может включать сниженное либидо. B . У человека в выраженной степени наблюдаются по крайней мере несколько следующих дополнительных симптомов депрессивного расстройства (или многие из перечисленных симптомов в меньшей степени) в тече- ние не менее 2 недель: Нарушение сна или излишне продолжительный сон  Значимое изменение аппетита или массы тела (пониже- ние или снижение)  Убежденность в своей никчемности или чрезмерное чувство вины  Утомляемость или вялость Пониженная способность концентрироваться и удер- живать внимание при выполнении заданий Нерешительность  Видимое тревожное возбуждение или двигательное беспокойство  Замедленные по сравнению с обычным состоянием движения или речь Ощущение безысходности при мысли о будущем Суицидальные мысли или действия. C . Человек испытывает значительные трудности при вы- полнении повседневных занятий в личной, семейной, общественной, образовательной, профессиональной или другой важной сфере . » Если А, В и С – все 3 – наблюдаются в течение не менее 2 недель, вероятно депрессивное расстройство средней или тяжелой степени. Может отмечаться бред* или галлюцинации*. Проверь- те их наличие. При наличии следует изменить лечение депрессивного расстройства соответствующим образом. Проконсультируйтесь со специалистом. » Если симптомы человека не соответствуют критери- ям депрессивного расстройства средней или тяжелой степени, перейдите в раздел ПРОЧ для оценки и лечения существующих жалоб . Вопрос 2 для оценки состояния: есть ли другие возможные объяснения симпто- мов (отличные от депрессивного расстройства средней или тяжелой степени)? » Исключите сопутствующие соматические заболевания, симптомы которых могут напоминать таковые депрес- сивного расстройства . Исключите и назначьте лечение анемии, недостаточности питания, гипотиреоза*, инсульта и побочных эффектов лекарственных средств (например, изменения настрое- ния при приеме стероидов*). » Исключите маниакальный(е) эпизод(ы) в анамнезе. Проверьте, был ли в прошлом период, когда одно- временно присутствовали несколько из следующих симптомов: X сниженная потребность во сне; X приподнятое настроение, возбуждение или раздражи- тельность; X скачка мыслей, легкая переключаемость внимания; X повышенная активность, ощущение прилива энергии или ускоренная речь; X импульсивное или беспокойное поведение, например чрезмерное увлечение играми, чрезмерная трата де- нег, принятие важных решений без соответствующего планирования; X необоснованно повышенная самооценка. Оцените, в какой степени симптомы мешали повседнев- ным занятиям или несли угрозу человеку или окружаю- щим. Например: X Была ли ваша чрезмерная активность проблемой для вас или вашей семьи? Кто-нибудь пытался госпита- лизировать или держать вас взаперти в этот период из-за вашего поведения?  В анамнезе есть маниакальные(е) эпизод(ы), если верно следующее: X несколько из 6 вышеперечисленных симптомов сохра- нялись более 1 недели; X симптомы значительно мешали повседневным заняти- ям или несли угрозу человеку или окружающим.  Если когда-либо был маниакальный эпизод, вероятно, что депрессия – часть другого расстройства, называе- мого биполярным расстройством*, и требует другого лечения (см. врезку ДЕП 2 в конце этого раздела). » Исключите нормальные реакции на тяжелую утрату (например, утрату близкого человека, перемещение в другую местность) (см. раздел ГОРЕ).  Более вероятно, что наблюдаемая реакция – нормальная реакция на тяжелую утрату, если: X со временем без клинического вмешательства происходит значимое улучшение; X отсутствуют все следующие симптомы: • чувство никчемности • суицидальные мысли • замедленные по сравнению с обычным состоянием движения или речь • психотические симптомы (бред или галлюцинации) X В анамнезе нет депрессивного расстройства или маниакального эпизода и X симптомы незначимо мешают повседневным занятиям. • Исключение: нарушенное функционирование может быть частью нормальной реакции на утрату близко- го человека, если оно допустимо местной культурой. 23 Д ЕП » Исключите пролонгированную реакцию горя: симптомы включают серьезную озабоченность или сильное стрем- ление к умершему, сопровождающееся сильным эмоцио- нальным страданием и существенными трудностями в выполнении повседневных занятий в течение как мини- мум последних 6 месяцев (и в течение периода, значитель- но превышающего принятый местными обычаями). При подозрении на это расстройство проконсультируйтесь со специалистом. Вопрос 3 для оценки состояния: имеется ли в настоящее время сопутствующее психическое и неврологическое расстройство или расстройство, связанное с употреблением наркотиков и других веществ (ПНВ), которое требует лечения? » Оцените состояние на предмет наличия мыслей или планов самоповреждения или самоубийства (см. раздел СУИ) . » Оцените состояние на предмет пагубного употребления алкоголя или наркотических средств (см. раздел ВЕЩ) . » Если выявлено сопутствующее расстройство ПНВ, одновре- менное назначьте лечение этого расстройства и депрессив- ного расстройства средней или тяжелой степени. Появляется все больше данных в пользу того, что краткое психологическое лечение могут проводить обученные и курируемые люди, не являющие специалистами, или члены местного сообщества. 24 Д ЕП Психосоциальные меры 1 . Проводите психообразование » Ключевая информация для пациента и лиц, осуществляю- щих уход: Депрессия – очень распространенное расстройство, которое может развиться у каждого.  Возникновение депрессии не означает, что человек сла- бый или ленивый. Негативное отношение окружающих (например, «будь сильнее», «соберись») может быть связано с тем, что де- прессия – неявное расстройство (в отличие от перелома или раны), и с ложным представлением, что люди могут легко контролировать депрессию силой воли.  У людей с депрессией обычно нереалистичное нега- тивное мнение о самих себе, их жизни и будущем. Их текущая ситуация может быть очень тяжелой, но депрес- сия может вызывать необоснованные мысли о собствен- ной безнадежности и никчемности. Эти взгляды обычно уходят по мере излечения депрессии. Даже если это сложно, человек должен пытаться выпол- нять как можно больше из нижеперечисленных занятий, поскольку они могут поднять настроение: X постараться возобновить (или продолжить) занятия, которые раньше доставляли удовольствие; X постараться придерживаться режима сна и бодрство- вания; X обеспечивать как можно большую физическую актив- ность; X постараться регулярно питаться, несмотря на измене- ние аппетита; X постараться проводить больше времени с близкими друзьями и членами семьи; X постараться как можно больше участвовать в жизни местного сообщества и другой общественной деятель- ности. Человек должен знать о возможности появления мыслей о самоповреждении или самоубийстве. Если он заметит такие мысли, он должен не следовать им, а рассказать о них близкому человеку и немедленно обратиться за помощью. 2 . Предложите психосоциальную поддержку в соответствии с рекомендациями в разделе «Принципы снижения стресса и укрепления социальной поддержки» (см . раздел «Общие принципы оказания помощи») » Воздействуйте на психосоциальные факторы, вызывающие у человека стресс в настоящий момент. » Оказывайте дополнительную социальную поддержку. Постарайтесь возобновить прошлые социальные связи человека. Выявите прошлую общественную деятель- ность, возобновление которой могло бы оказать прямую или косвенную психосоциальную поддержку (например, семейные встречи, посещение соседей, местные соци- ально-культурные мероприятия). » Научите человека, как справляться со стрессом. 3 . Если имеется обученный и курируемый психолог, рассмотрите возможность убедить людей с депрессивным расстройством средней или тяжелой степени провести краткий курс психотерапии, в зависимости от доступного метода: » консультирование по решению проблем* » межличностная психотерапия (МЛПТ)* » когнитивно-поведенческая терапия (КПТ)* » поведенческая активация*. 25 Д ЕП Медикаментозная терапия 1 . Рассмотрите возможность назначения антидепрессантов » Детям младше 12 лет: Не назначайте антидепрессанты. » Подросткам в возрасте 12–18 лет: Не рекомендуется назначать антидепрессанты в качестве первоочередного лечения. Сначала предложите психосо- циальные меры. » Взрослым:  Если у человека сопутствующее соматическое заболе- вание, проявления которого могут напоминать таковые депрессивного расстройства (см. вопрос 2 для оценки состояния), всегда сначала назначьте лечение этого заболевания. Рассмотрите возможность назначения антидепрессантов, если симптомы депрессивного рас- стройства не ослабевают после лечения сопутствующих соматических заболеваний.  Если вы подозреваете симптомы, являющиеся нормаль- ной реакцией на тяжелую утрату (см. вопрос 2 для оцен- ки состояния), не назначайте антидепрессанты. Обсудите с человеком и вместе решите, стоит ли назна- чать антидепрессанты. Объясните следующее: X Антидепрессанты не вызывают зависимости. X Очень важно принимать препарат каждый день в соответствии с указаниями врача. X В первые несколько дней могут возникать некоторые побочные эффекты (см. таблицу ДЕП 1), но обычно они проходят. X Обычно проходит несколько недель, прежде чем ста- новится заметно улучшение настроения, появляется больше заинтересованности или прилив сил. Обычно следует продолжать прием антидепрессантов в течение не менее 9–12 месяцев после того, как человек почувствует себя лучше. Не следует прекращать прием препаратов потому лишь, что человек почувствует некоторое улучшение (это не обезболивающее от головной боли). Расскажите человеку о рекомендуемом временном периоде приема препарата. 2 . Если решено назначить антидепрессанты, подберите подходящий препарат (см. таблицу ДЕП 1) » Выберите антидепрессант, исходя из возраста человека, сопутствующих заболеваний и профиля побочных эффек- тов препарата (см. таблицу ДЕП 1) . » У подростков 12 лет и старше:  Рассмотрите возможность назначения флуоксетина (но не другого селективного ингибитора обратного за- хвата серотонина (СИОЗС) и не трициклических антиде- прессантов (ТЦА)), только если симптомы сохраняются или ухудшаются, несмотря на психосоциальные меры. » У беременных или кормящих женщин:  по возможности избегайте назначения антидепрессан- тов; рассмотрите возможность применения антидепрес- сантов в самой низкой эффективной дозе, если нет улуч- шения в ответ на психосоциальные меры; если женщина кормит грудью, избегайте назначения флуоксетина. По возможности проконсультируйтесь со специалистом. » У пожилых людей: По возможности избегайте назначения амитриптилина. » У людей с сердечно-сосудистыми заболеваниями: Не назначайте амитриптилин. » У людей с суицидальными мыслями или планами: Флуоксетин – препарат первой линии. При непосред- ственном риске самоповреждения или самоубийства (см. раздел СУИ) выдавайте ограниченный запас анти- депрессантов (например, при каждом визите – только на одну неделю). Попросите лиц, осуществляющих уход за пациентом, хранить препараты у себя и следить за их приемом, а также часто наблюдать за подопечным для предупреждения передозировки препарата. Таблица ДЕП 1 . Антидепрессанты Амитриптилинa (ТЦАb ) Флуоксетин (СИОЗСc) Начальная доза для взрослых 25–50 мг перед сном 10 мг раз в день. Повысить до 20 мг через 1 неделю Начальная доза для подростков Неприменимо (не назначайте подросткам ТЦА) 10 мг раз в день Начальная доза для пожилых и людей с другими соматическими заболеваниями 25 мг перед сном 10 мг раз в день Повышение дозы у взрослых Повышение на 25–50 мг в неделю Если в течение 6 недель нет ответа, повысьте дозу до 40 мг раз в день Обычная эффективная доза для взрослых 100–150 мг (высшая доза – 300 мг)d 20–40 мг (высшая доза – 80 мг) Обычная эффективная доза для подрост- ков, пожилых и людей с другими сомати- ческими заболеваниями 50–75 мг (высшая доза – 100 мг) Не назначать подросткам 20 мг (высшая доза – 40 мг) Серьезные и редкие побочные эффекты Сердечная аритмия Пролонгированная акатизия* Нарушения гемостаза у людей, принимающих аспирин или другие нестероидные противовос- палительные средства* Идеи самоповреждения (в особенности у подрост- ков и молодых людей). Частые побочные эффекты Ортостатическая гипотензия (риск паде- ния), сухость во рту, запор, затруднения с мочеиспусканием, головокружение, нечет- кость зрения и седация Головная боль, беспокойство, нервозность, нару- шения со стороны желудочно-кишечного тракта, обратимая сексуальная дисфункция Внимание Немедленно прекратите лечение в слу-чае маниакального эпизода Немедленно прекратите лечение в случае маниа- кального эпизода a Входит в состав межучрежденческого набора для оказания неотложной медицинской помощи (ВОЗ, 2011 г.) b ТЦА означает трициклический антидепрессант c СИОЗС означает селективный ингибитор обратного захвата серотонина d Минимальная эффективная доза у взрослых: 75 мг (седация может наблюдаться и при меньших дозах). Врезка ДЕП 2. Медикаментозное лечение текущего депрессивного эпизода у человека с биполярным расстройством 26 Д ЕП 3 . Последующее наблюдение » Предложите регулярное последующее наблюдение. Составьте план регулярных посещений в соответствии с «Принципами лечения» (см. раздел «Общие принципы оказания помощи») и проводите последующее наблюде- ние в соответствии с этим планом.  Запланируйте вторую встречу в течение 1 недели и по- следующие встречи – в зависимости от течения болезни. » Контролируйте ответ на антидепрессанты. Проявление эффекта антидепрессантов может занять несколько недель. Перед повышением дозы тщательно оцените ответ.  Если развиваются симптомы маниакального эпизода (см. вопрос 2 для оценки состояния), немедленно отме- ните препарат и перейдите к разделу ПСИ для лечения маниакального эпизода.  Рассмотрите возможность постепенной отмены препара- та через 9–12 месяцев после исчезновения симптомов. Снижайте дозу постепенно в течение не менее 4 недель. Никогда не назначайте людям с биполярным расстройствам антидепрессанты без нормотимиче- ских средств, поскольку прием антидепрессантов может привести к маниакальному эпизоду. Если у человека в анамнезе есть маниакальный эпизод: » Проконсультируйтесь со специалистом. » Если не получается сразу получить консультацию специалиста, назначьте антидепрессант в комбинации с нормоти- мическим средством, таким как карбамазепин или вальпроевая кислота (см. таблицу ДЕП 2) . Начните с низкой дозы препарата. Постепенно повышайте дозу в последующие недели. X По возможности избегайте назначения карбамазепина и вальпроевой кислоты женщинам, которые беремен- ны или планируют беременность, по причине потенциальной опасности препарата для плода. Решение о на- значении нормотимических препаратов беременной женщине следует принимать вместе с ней самой. Следует принимать во внимание степень тяжести и частоту маниакальных и депрессивных эпизодов. Проконсультируйтесь со специалистом по поводу продолжающегося лечения биполярного расстройства. » Сообщите пациенту, что при развитии симптомов маниакального эпизода необходимо немедленно прекратить при- ем антидепрессантов и обратиться за помощью; то же самое сообщите и лицам, осуществляющим уход за человеком. Таблица ДЕП 2 . Нормотимические средства при биполярном расстройстве Карбамазепин Вальпроевая кислота Начальная доза 200 мг/день 400 мг/день Обычная эффективная доза 400–600 мг/день(высшая доза – 1400 мг/день) 1000–2000 мг/день (высшая доза – 2500 мг/день) Режим дозирования Два раза в день, прием внутрь Два раза в день, прием внутрь Редкие, но серьезные побочные эффекты  Тяжелая кожная сыпь (синдром Стивенса – Джонсона*, токсический эпидермальный некролиз*)  Угнетение костного мозга*  Сонливость  Спутанность сознания Частые побочные эффекты  Сонливость  Нарушение походки  тошнота  Летаргия  Седация  Тремор  Тошнота, диарея  Увеличение массы тела  Преходящее выпадение волос (рост волос восстанавливается в течение 6 месяцев)  Нарушение функции печени 27 П ТС Р ПостТравматическое Стрессовое Расстройство ПТСР Как упоминалось в разделе, посвященном острому стрессовому расстройству (ОСР), у взрослых, подростков и детей часто развиваются различные психологические реакции или симптомы после сильного стресса в чрезвычайных гуманитарных ситуациях . У боль- шинства людей эти симптомы со временем проходят . Если специфический, характерный комплекс симптомов (повторяющиеся чувства, избе- гание и повышенное чувство опасности) сохраняется в течение более месяца после по- тенциально травмирующего события*, у человека могло развиться посттравматическое стрессовое расстройство (ПТСР) . Несмотря на свое название, ПТСР не обязательно единственное или основное расстрой- ство, вызванное потенциально травмирующими событиями . Такие явления могут вы- зывать многие другие психические и неврологические расстройства и расстройства, связанные с употреблением наркотиков и других веществ (ПНВ), описанные в настоящем руководстве . » » » 28 П ТС Р 8 Описание ПТСР согласовано с текущим проектом МКБ-11, но с одним отличием: МКБ-11 позволяет ставить диагноз ПТСР в течение 1 месяца (например, нескольких недель) после события. Проект МКБ-11 не включает неспецифические симптомы ПТСР, такие как оцепенение и тревожное возбуждение. Вопрос 1 для оценки состояния: человек перенес потенциально травмирую- щее событие более 1 месяца назад? » Спросите, перенес ли человек потенциально травми- рующее событие. Это любое устрашающее или пугающее событие, такое как физическое или сексуальное насилие (включая домашнее насилие), присутствие при актах же- стокости, разрушение собственного жилища или крупные аварии или травмы. Вы можете задать следующие вопросы: Как на вас повлияла катастрофа/конфликт? Ваша жизнь была в опасности? Вы испытали нечто очень страшное или ужасающее или чувствовали себя очень плохо дома или в местном сообществе? » Если человек перенес потенциально травмирующее собы- тие, спросите, когда это произошло. Вопрос 2 для оценки состояния: если потенциально травмирующее событие произошло более 1 месяца назад, есть ли у человека ПТСР?8 » Оцениваются: Симптомы повторного переживания. Это повторяю- щиеся и нежелательные воспоминания о событии, как будто оно происходит здесь и сейчас (например, в форме кошмарных снов, ярких повторных переживаний* или навязчивых воспоминаний*, сопровождающихся силь- ным страхом или ужасом). X У детей это может включать многократное проигрыва- ние или рисование событий. У маленьких детей могут быть кошмарные сны с нечетким содержанием. Симптомы избегания. Включают сознательное избега- ние мыслей, воспоминаний, занятий или ситуаций, на- поминающих человеку о событии (например, избегание разговоров на темы, которые напоминают о событии, или избегание посещения мест, где произошло событие). Симптомы, связанные с повышенным чувством опасности (часто называемые «симптомами перевоз- буждения»). Они включают чрезмерное беспокойство и ожидание опасности или сильную реакцию на громкие звуки или неожиданные движения (например, человек нервный или «на взводе»). Существенно мешают повседневным занятиям. » Если все вышеперечисленное сохраняется примерно в течение 1 месяца после события, вероятно ПТСР. Вопрос 3 для оценки состояния: имеется ли сопутствующее расстройство? » Оцените состояние на предмет наличия и назначьте лече- ние любого сопутствующего соматического заболева- ния, которое может объяснить симптомы. » Оцените состояние на предмет наличия и назначьте лечение всех остальных расстройств ПНВ, описанных в настоящем руководстве. 29 П ТС Р 1 . Расскажите о ПТСР » Объясните, что: У многих людей ПТСР со временем проходит без лечения, а кому-то требуется лечение. Люди с ПТСР многократно переживают нежелательные воспоминания о травмирующем событии. Когда это про- исходит, у них могут возникать такие эмоции, как страх и ужас, сходные с чувствами, которые они испытали во время события. У них также могут быть кошмарные сны. Людям с ПТСР часто кажется, что они все еще в опасно- сти, и они могут быть очень напряжены. Их легко испу- гать (нервные) или они постоянно ожидают опасности. Люди с ПТСР стараются избегать любых напоминаний о событии. Такое избегание может создать в их жизни проблемы. Если применимо: у людей с ПТСР иногда бывают другие соматические и психические нарушения, такие как боли по всему телу, вялость, утомляемость, раздражитель- ность и подавленное настроение. » Посоветуйте человеку: Придерживаться обычного ежедневного распорядка, насколько это возможно. Поговорить с близкими людьми о том, что случилось и как он себя чувствует, но только, когда он будет к этому готов. Найти себе расслабляющие занятия, чтобы снизить тревожность и напряжение. Не употреблять алкоголь или наркотики, чтобы спра- виться с симптомами ПТСР. 2 . Предложите психосоциальную поддержку в соответствии с рекомендациями в разделе «Принципы снижения стресса и укрепления социальной поддержки» (см. раздел «Общие принципы оказания помощи») » Воздействуйте на психосоциальные факторы, вызывающие у человека стресс в настоящий момент. Если человек стал жертвой серьезного нарушения прав человека, обсудите с ним возможность направления в проверенную защитную или правозащитную организацию. » Оказывайте дополнительную социальную поддержку. » Научите человека, как справляться со стрессом. 3 . Если доступен обученный и курируемый психолог, рассмотрите возможность направления на: » когнитивно-поведенческую терапию с акцентом на травми- рующем переживании* » десенсибилизацию и переработку движениями глаз (ДПДГ)* 4 . Рассмотрите возможность назначения взрослым антидепрессантов (селек- тивных ингибиторов обратного захвата серотонина или трициклических анти- депрессантов), если когнитивно-поведенческая терапия, ДПДГ или методики управления стрессом неэффективны или недоступны . » В разделе, посвященном депрессивному расстройству средней или тяжелой степени, более подробно описано назначение антидепрессантов (см. раздел ДЕП). » НЕ предлагайте антидепрессанты для лечения ПТСР у детей и подростков. 5. Последующее наблюдение » Составьте план регулярных посещений в соответствии с «Принципами лечения» (см. раздел «Общие принципы оказания помощи») и проводите последующее наблюде- ние в соответствии с этим планом. » Запланируйте вторую встречу в течение 2–4 недель и по- следующие встречи – в зависимости от течения болезни.

П СИ 31 Психоз ПСИ Взрослые и подростки, страдающие психозом, могут быть твердо убеждены в существо- вании нереальных вещей или испытывать нереальные ощущения . Окружающие обычно считают их убеждения и переживания ненормальными . Люди, страдающие психозом, часто не понимают, что у них нарушено психическое состояние . У них часто возникают проблемы во многих сферах жизни . Гуманитарные катастрофы могут сопровождаться возникновением крайне стрессовых ситуаций, появлением страха, разрушением системы социальной поддержки и системы здравоохранения, а также проблемами в обеспечении лекарственными препаратами . Эти изменения могут приводить к развитию острого психоза или усугублению имеющих- ся симптомов этого заболевания . В чрезвычайных ситуациях люди, страдающие психо- зом, крайне уязвимы, так как в таких случаях высока вероятность нарушения их прав в различных сферах жизни – они рискуют остаться без надзора и опеки, лишиться места жительства, стать жертвой надругательств и социальной стигматизации . » » » » » Вопрос 1 для оценки состояния: есть ли у человека психоз? » Необходимо отметить, что несмотря на то, что у людей, страдающих психозом, могут быть патологические мысли, ненормальные убеждения или речевые нарушения, это не значит, что все, что они говорят, неправильно или вымыш- лено. Для принятия правильного решения о наличии психо- за очень важно внимательно вслушаться в речь человека. Для всесторонней оценки состояния может потребоваться несколько встреч. Часто ценную информацию можно полу- чить от лиц, осуществляющих уход. » Оцените состояние на предмет наличия следующих откло- нений: Бред* (стойкие ложные убеждения или подозрения, которые сохраняются даже при наличии доказательств обратного) XРекомендация: попробуйте изучить состояние более подробно: спросите человека, что он имеет в виду, и внимательно выслушайте ответ. Галлюцинации* (человек видит, слышит или ощущает то, чего в действительности нет) XСлышите ли или видите ли вы то, что другие не слы- шат и не видят? Дезорганизация мышления: человек перескакивает с одной темы на другую без логических связей, и за его речью трудно следить Необычные переживания, например убеждение чело- века, что другие люди передают ему свои мысли или забирают его мысли или что его мысли передаются другим людям Поведенческие нарушения, например странное, вызывающее, бесцельное или возбужденное поведение, поддержание необычного положения тела или полная неподвижность Длительно сохраняющиеся симптомы, которые при- водят к нарушению нормальной жизнедеятельности, в том числе: Xвялость или отсутствие мотивации заниматься повсед- невными делами и работой; Xапатия и социальная самоизоляция; Xплохой уход или полное отсутствие ухода за собой; Xослабление эмоциональных реакций и способности выражать эмоции. » Психоз может иметь место при наличии нескольких симптомов. Всегда оценивайте непосредственный риск суицида (см. раздел СУИ), нанесения повреждений этим человеком другим людям и нанесения повреждений данному человеку другими людьми. Вопрос 2 для оценки состояния: есть ли острые соматические состояния, которые могут приводить к появлению симптомов психоза и на которые можно повлиять? » Исключите развитие делирия* вследствие острых сома- тических состояний, таких как травма головы, инфекция (например, малярийная кома, сепсис* или уросепсис*), обезвоживание и нарушения обмена веществ (например, гипогликемия*, гипонатриемия*). » Исключите побочные эффекты медикаментозной терапии (например, некоторых противомалярийных препаратов). » Исключите алкогольную или лекарственную интоксика- цию или синдром отмены алкоголя или лекарственных препаратов (см. раздел СУИ). Спросите человека об употреблении алкоголя и примене- нии седативных или других лекарственных препаратов. Проверьте, есть ли запах алкоголя. Вопрос 3 для оценки состояния: соответствует ли состояние человека критериям маниакального эпизода? » Исключите манию. Оцените состояние на предмет наличия следующих отклонений: сниженная потребность во сне; приподнятое настроение, возбуждение или раздражи- тельность; скачка мыслей, легкая переключаемость внимания; повышенная активность, ощущение прилива энергии или ускоренная речь; импульсивное или беспокойное поведение, например чрезмерное увлечение играми, чрезмерная трата денег, принятие важных решений без соответствующего плани- рования; необоснованно повышенная самооценка. » Маниакальный эпизод может иметь место при наличии нескольких из этих симптомов в течение одной недели; при этом либо данные симптомы серьезно нарушают повсед- невную жизнь человека, либо невозможно обеспечить безопасность при нахождении человека дома. П СИ 32 1 . Психоз при отсутствии острых соматических состояний, которые могут быть его причиной » Назначьте пероральный нейролептик. Рассмотрите возможность внутримышечного (в/м) введения препара- та (только в тех случаях, когда прием препаратов внутрь невозможен). Узнайте, принимал ли человек ранее ка- кой-либо нейролептик, который позволял контролировать симптомы. Если да, назначьте этот препарат в той же дозе. При отсутствии этого препарата назначьте другой препарат. На начальном этапе лечения будет необходимо участие лица, осуществляющего уход, или медицинского работника, которые должны будут хранить препарат и выдавать его пациенту, чтобы обеспечить соблюдение режима лечения. Назначайте одновременно только один нейролептик (например, галоперидол; см. таблицу ПСИ 1). Начинайте с низкой дозы и повышайте дозу посте- пенно: начинайте с минимальной терапевтической дозы и медленно повышайте ее до достижения необходимого эффекта на фоне минимальной эффективной дозы. Перед тем как принять решение о неэффективности лечения, оцените эффект препарата при применении его в обычной эффективной дозе в течение достаточно- го количества времени (как минимум 4–6 недель) (см. таблицу ПСИ 1). XЖенщинам, планирующим беременность, беремен- ным и кормящим матерям назначайте препарат в минимальной эффективной дозе для приема внутрь. Если тревожное возбуждение не удается устранить толь- ко с помощью нейролептика, назначьте бензодиазепин (например, диазепам; максимальная доза 5 мг внутрь) и незамедлительно проконсультируйтесь со специалистом. Проводите лечение побочных эффектов. XПри наличии выраженных острых экстрапирамид- ных побочных эффектов*, таких как паркинсонизм (сочетание тремора*, ригидности мышц и уменьшения движений тела) или акатизия* (неспособность спокой- но сидеть): • уменьшите дозу нейролептика; • если, несмотря на снижение дозы, экстрапирамидные побочные эффекты сохраняются, рассмотрите возможность назначения антихолинергических препаратов на короткий срок (например, биперидена на 4–8 недель; см. таблицу ПСИ 2). XПри наличии острой дистонии (острого спазма мышц, обычно мышц шеи, языка и жевательных мышц): • временно отмените нейролептик и назначьте антихолинергический препарат (например, бипериден; см. таблицу «ПСИ 2»). При отсутствии этих препаратов можно использовать диазепам для обеспечения расслабления мышц. По возможности проконсультируйтесь со специалистом по вопросам продолжительности лечения и отмены нейролептиков. XОбычно рекомендуется продолжать прием нейро- лептика в течение как минимум 12 месяцев после исчезновения симптомов. XПри отмене препарата необходимо медленно снижать его дозу (в течение нескольких месяцев). XНельзя резко отменять прием препарата. 2 . Симптомы психоза, вызванные острыми соматическими состояниями (например, синдромом отмены алкоголя или делирием) » Проводите лечение острой патологии . Информация по лечению синдрома отмены алкоголя приведена во врезке 1 в разделе ВЕЩ. При наличии других острых соматических состояний помимо синдрома отмена алкоголя при необходимо- сти назначьте пероральный нейролептик (например, галоперидол; начальная доза 0,5 мг с повышением до 2,5–5 мг 3 раза в день). Назначайте нейролептик только при необходимости устранить тревожное возбуждение, симптомы психоза и агрессию. Как только эти симптомы исчезнут, отмените препарат. Рассмотрите возможность внутримышечного введения препарата (только в тех слу- чаях, когда прием препаратов внутрь невозможен). 3 . Маниакальный эпизод » Назначьте пероральный нейролептик (см. выше п. 1 в разделе «Медикаментозная терапия»). » При сохранении выраженного тревожного возбуждения несмотря на прием нейролептика рассмотрите возмож- ность дополнительного назначения бензодиазепина (например, диазепама; максимальная доза 5 мг внутрь) и незамедлительно проконсультируйтесь со специалистом. » Маниакальный эпизод – это проявление биполярно- го расстройства*. После купирования маниакального приступа человека необходимо обследовать и назначить нормотимическое средство (например, вальпроевую кислоту или карбамазепин) для лечения биполярного расстройства. Проконсультируйтесь со специалистом и (или) следуйте рекомендациям по лечению биполярного расстройства, приведенным в полной версии «Руковод- ства mhGAP по принятию мер в отношении психиче- ских и неврологических расстройств». П СИ 33 A . Медикаментозная терапия П СИ 34 Таблица ПСИ 2 . Антихолинергические препараты Препарат Бипериденa Тригексфенидил Начальная доза 1 мг 2 р/день 1 мг/день Обычная эффективная доза 3–6 мг/день (высшая доза – 12 мг) 5–15 мг/день (высшая доза – 20 мг) Путь введения Внутрь Внутрь Значимые побочные эффекты: Спутанность сознания, нарушение памяти (особенно в пожилом возрасте) +++ +++ Седация (особенно в пожилом возрасте) + + Затрудненное начало мочеиспускания ++ ++ a Входит в состав межучрежденческого набора для оказания неотложной медицинской помощи (ВОЗ, 2011 г.) Таблица ПСИ 1 . Нейролептики Препарат Галоперидолa Хлорпромазин Рисперидон Начальная доза 2,5 мг/день 50–75 мг/день 2 мг/день Обычная эффективная доза 4–10 мг/день (высшая доза – 20 мг) 75–300 мг/деньb (высшая доза – 1000 мг) 4–6 мг/день (высшая доза – 10 мг) Путь введения Внутрь/внутримышечно Внутрь Внутрь Значимые побочные эффекты: Экстрапирамидные побочные эффекты* +++ + + Седация (особенно в пожилом возрасте) + +++ + Затрудненное начало мочеиспускания ++ Ортостатическая гипотензия* + +++ + Злокачественный нейролептический синдром* Редкос Редкос Редкос a Входит в состав межучрежденческого набора для оказания неотложной медицинской помощи (ВОЗ, 2011 г.) b В тяжелых случаях может потребоваться доза до 1 г. c При подозрении на этот синдром необходимо незамедлительно отменить нейролептики, обеспечить общее охлаждение организма пациента и адекватную инфузионную терапию. П СИ 35 B . Психосоциальные меры Для всех случаев: 1 . Проводите психообразование Ключевая информация для пациента и лица (лиц), осуществляющих уход: » Психоз можно лечить, и человек может вылечиться. » Стресс может усугубить симптомы психоза. » Постарайтесь, насколько возможно, продолжать обще- ственную деятельность, учебу и работу, даже если это сложно в чрезвычайной ситуации. » Не употребляйте алкоголь, наркотики, получаемые из конопли, и безрецептурные препараты, так как они могут усугубить симптомы психоза. » Люди, страдающие психозом, должны регулярно принимать назначенные препараты и посещать врача, который будет осуществлять наблюдение. » Обращайте внимание на повторное возникновение и усугубление симптомов психоза. Обратитесь в лечебное учреждение, так как может возникнуть необходимость изменить лечение. Информация для лиц, осуществляющих уход: » Не пытайтесь убедить человека, что его убеждения и пере- живания ложные или не соответствуют действительности. » Старайтесь вести себя нейтрально и оказывать поддерж- ку человеку, даже когда он ведет себя необычно или агрессивно. » Старайтесь не вступать в конфликты с подопечным и не проявлять враждебность по отношению к нему. » Старайтесь не ограничивать свободу передвижения подо- печного. Старайтесь не сдерживать подопечного, принимая при этом основные меры по обеспечению его безопасности и безопасности других людей. » Психоз не возникает в результате колдовства и воздей- ствия духов. » Не возлагайте вину на человека и других членов семьи и не обвиняйте их в том, что они стали причиной развития психоза. » Если женщина недавно родила ребенка, не оставляйте ее одну с ребенком – это позволит обеспечить безопасность новорожденного. 2 . Способствуйте повторной социальной адаптации человека » Пообщайтесь с местными общественными лидерами для того, чтобы местное сообщество легче приняло человека, страдающего психозом, и терпимее относилось к нему. » Способствуйте участию человека в экономической и соци- альной жизни местного сообщества. » Свяжитесь с сотрудниками организаций, представляющих ресурсы местного сообщества, такими как местные меди- цинские работники, сотрудники служб защиты, социальные работники и сотрудники служб по работе с инвалидами. Попросите их помочь человеку вернуться к нормальной общественной жизни, учебе и работе. 3 . Обеспечьте помощь и поддержку лицам, осуществляющим уход, в соответствии с «Принципами снижения стресса и укрепления социальной поддержки» (см . раздел «Общие принципы оказания помощи») C . Последующее наблюдение » Составьте план регулярных посещений в соответствии с «Принципами лечения» (см. раздел «Общие принципы оказания помощи») и проводите последующее наблюде- ние в соответствии с этим планом. » Назначьте следующее посещение в течение недели, а по- следующие – с учетом изменения состояния пациента. » Лечение нейролептиками следует проводить в течение как минимум 12 месяцев после полного исчезновения сим- птомов. По возможности проконсультируйтесь со специ- алистом относительно продолжения терапии или отмены препарата.

37 ЭП И Эпилепсия/ПрипадкиЭПИ Эпилепсия – самое частое из всех психических и неврологических расстройств и рас- стройств, связанных с употреблением наркотиков и других веществ (ПНВ), по поводу ко- торого назначают лечение в чрезвычайных гуманитарных ситуациях в странах с низким и средним доходом . Эпилепсией болеют люди всех возрастов, в том числе дети . Эпилепсия – это хроническое неврологическое заболевание, проявляющееся повторя- ющимися спонтанными припадками, которые развиваются вследствие патологической электрической активности в головном мозге . Существуют различные формы эпилепсии . Данный раздел посвящен наиболее распространенной форме – эпилепсии с судорожны- ми припадками . Эта форма эпилепсии проявляется припадками, в результате которых происходят внезапные непроизвольные сокращения мышц, сменяющиеся расслаблением мышц, что приводит к дрожанию или оцепенению (ригидности) туловища и конечностей . Во время припадков часто нарушается сознание . Человек, у которого развились судороги, может упасть и получить травму . В чрезвычайных гуманитарных ситуациях часто возникают проблемы с поставками про- тивоэпилептических препаратов . В отсутствие возможности постоянно получать эти препараты у пациентов с эпилепсией возможно повторное развитие припадков, которые в некоторых случаях могут угрожать жизни . Информация о процедуре оценки состояния и необходимых действиях в отношении людей, испытывающих судороги или находящихся без сознания после припадка*, приведена во врезке ЭПИ 2 на стр. 42. » 38 ЭП И Вопрос 1 для оценки состояния: соответствует ли состояние человека критериям судорожного припадка? » Спросите у человека, не было ли у него каких-либо из ни- жеперечисленных симптомов (задайте те же вопросы лицу, осуществляющему уход):  судорожные движения, продолжавшиеся более 1–2 минут;  потеря или нарушение сознания;  скованность или ригидность туловища или конечностей в течение более 1–2 минут;  прикусывание языка, или образование синяков на языке, или телесные повреждения;  недержание мочи или кала во время припадка.  После исчезновения патологических движений могут на- блюдаться спутанность сознания, сонливость или пове- денческие нарушения. Человек также может жаловаться на чувство усталости, головную боль или боль в мышцах. » Состояние человека соответствует критериям судорож- ного припадка, если у него наблюдаются судорожные движения и как минимум два других симптома из выше- приведенного перечня. » Наличие только одного или двух из вышеперечисленных критериев может указывать на бессудорожные припадки или другие нарушения.  Если у человека было несколько бессудорожных припад- ков, обсудите эту ситуацию со специалистом.  При подозрении на другие нарушения принимайте соот- ветствующие меры.  Проведите повторную оценку состояния через 3 месяца. Вопрос 2 для оценки состояния: есть ли какое-либо острое состояние, которое могло бы вызвать судорожный припадок? » Оцените состояние человека на предмет наличия призна- ков и симптомов нейроинфекции, таких как:  лихорадка;  головная боль;  раздражение мозговых оболочек* (например, ригид- ность затылочных мышц). » Проверьте наличие других возможных причин судорог, таких как:  травма головы;  нарушение обмена веществ* (например, гипогликемия*, гипонатриемия*);  алкогольная или лекарственная интоксикация или синдром отмены алкоголя или лекарственных пре- паратов (см. врезку ВЕЩ 1 на стр. 50). » При выявлении острого состояния, являющегося причи- ной судорожного припадка, проводите соответствующее лечение этого состояния.  В этих случаях поддерживающая терапия противоэпи- лептическими препаратами не требуется. » При подозрении на нейроинфекцию*, травму головы или нарушение обмена веществ незамедлительно направьте пациента в стационар.  У детей (в возрасте от 6 месяцев до 6 лет) на нейроин- фекцию может указывать лихорадка в сочетании с любым из следующих признаков сложных фебриль- ных припадков: X фокальный припадок – припадок, начинающийся в одной части тела; X продолжительный припадок – припадок, продолжаю- щийся в течение более 15 минут; X повторный припадок – наличие более одного припад- ка с момента развития заболевания.  Отсутствие всех трех признаков у ребенка с лихорадкой может указывать на простой фебрильный припадок. Проводите лечение лихорадки и поиск вызвавшей ее причины в соответствии с местным вариантом стратегии «Интегрированное ведение болезней детского воз- раста». Наблюдайте за ребенком в течение 24 часов. » Проведите повторную оценку состояния через 3 месяца. Вопрос 3 для оценки состояния: является ли судорожный припадок проявлением эпилепсии, если не выявлено никакого острого состояния, которое могло бы быть причиной припадка? » В таких случаях критерием эпилепсии считается развитие двух или более спонтанных судорожных припадков в два разных дня в течение последних 12 месяцев. » При наличии одного судорожного припадка за последние 12 месяцев в отсутствие острого состояния, которое могло быть его причиной, противоэпилептическая терапия не требуется. Проведите повторный осмотр через 3 месяца. 39 ЭП И Рисунки A–D: «Восстановительное положение» A C B D 1 . Предоставьте человеку и лицу, осуществляющему уход за ним, информацию об эпилепсии » Объясните следующее:  Что такое эпилепсия и каковы ее причины: X Эпилепсия – это хроническое заболевание, но медика- ментозная терапия позволяет устранить припадки у 75 % людей. X При эпилепсии отмечаются повторные припадки. Припадок связан с возникновением патологической электрической активности в головном мозге. X Эпилепсия не возникает в результате колдовства и воздействия духов. X Эпилепсия не заразна. Эпилепсия не передается через слюну.  Что важно знать об образе жизни: X Люди с эпилепсией могут вести нормальный образ жизни: • Они могут вступать в брак и иметь здоровых детей. • Они могут успешно и безопасно выполнять большинство работ. • Дети с эпилепсией могут ходить в школу. X Людям с эпилепсией не следует: • заниматься профессиональной деятельностью, требующей выполнения работ вблизи тяжелого оборудования или огня; • готовить пищу на открытом огне; • плавать в одиночестве; • употреблять алкоголь и рекреационные наркотики; • смотреть на мигающий свет; • изменять режим сна (например, спать меньше, чем обычно).  Что делать дома в случае развития припадка (информация для лиц, осуществляющих уход): X Если на момент начала припадка человек стоит или сидит, осторожно помогите ему сесть или лечь на зем- лю, что позволит предотвратить травму при падении. X Обеспечьте человеку возможность нормально дышать. Ослабьте давление одежды вокруг шеи. X Положите человека в «восстановительное положение» (см. рисунки A–D ниже). A . Встаньте на колени на пол сбоку от человека. Согните его руку, находящуюся ближе к вам, под прямым углом и положите ее так, чтобы кисть была направлена вверх к голове (см. рисунок A ниже). B . Другую руку положите под голову так, чтобы тыльная сто- рона кисти соприкасалась с щекой (см. рисунок B ниже). C . Согните ногу, находящуюся дальше от вас, под прямым углом. Аккуратно переверните человека на бок, потянув за согнутое колено (см. рисунок C ниже). D . Рука, находящаяся сверху, должна поддерживать голову, а рука, находящаяся снизу, будет ограничителем и не даст человеку откатиться слишком далеко (см. рисунок D ниже). Обеспечьте проходимость дыхательных путей человека, слегка запрокинув его голову назад и под- няв подбородок; убедитесь, что дыхательные пути свободны. При таком положении язык не перекрывает дыхательные пути, а человек может свободнее дышать и не захлебнется слюной и рвотными массами. X Постарайтесь не сдерживать человека и не удержи- вать его на полу. X Не кладите ничего человеку в рот. X Уберите от человека все тяжелые и острые предметы, чтобы предотвратить травму. X Оставайтесь рядом с человеком до того, как припадок закончится и человек придет в сознание. » Попросите человека и лицо, осуществляющее уход за ним, вести простой дневник припадков (см. рисунок ЭПИ 1). 40 ЭП И 2 . Начните противоэпилептическую терапию или назначьте противоэпилептический препарат, который человек принимал ранее » Выясните, принимал ли человек когда-либо противоэпи- лептический препарат, который помогал устранить судоро- ги. Если да, назначьте этот препарат в той же дозе. » При отсутствии этого препарата назначьте другой препарат. » Выберите один противоэпилептический препарат (см. таблицу ЭПИ 1).  Учтите возможность развития побочных эффектов, влияния лекарственного препарата на сопутствующие заболевания* и лекарственного взаимодействия*. При необходимости используйте национальный фарма- цевтический справочник или фармацевтический справочник ВОЗ.  Начните с минимальной дозы и постепенно по- вышайте дозу до достижения полного контроля над припадками. » Объясните человеку и лицу, осуществляющему уход, следу- ющую информацию:  Схема дозирования препарата (см. таблицу ЭПИ 1).  Возможные побочные эффекты (см. таблицу ЭПИ 1). Большинство побочных эффектов имеют легкую сте- пень тяжести и через некоторое время исчезают. При развитии тяжелых побочных эффектов человек должен немедленно прекратить прием препарата и обратиться за медицинской помощью.  Важность соблюдения режима приема препарата. Про- пуск и резкое прекращение приема препарата может быть причиной повторных припадков. Препарат необхо- димо принимать каждый день в одно и то же время.  Время развития эффекта препарата. Обычно эффект препаратов развивается через несколько недель.  Длительность терапии. Медикаментозную терапию необ- ходимо продолжать до тех пор, пока у человека не будет припадков в течение как минимум двух лет.  Важность регулярного наблюдения. Таблица ЭПИ 1 . Противоэпилептические препараты Фенобарбиталa Карбамазепин Фенитоин Вальпроевая кислота Начальная доза для детей 2–3 мг/кг/день 5 мг/кг/день 3–4 мг/кг/день 15–20 мг/кг/день Обычная эффективная доза для детей 2–6 мг/кг/день 10–30 мг/кг/день 3–8 мг/кг/день (высшая доза – 300 мг/ день) 15–30 мг/кг/день Начальная доза для взрослых 60 мг/день 200–400 мг/день 150–200 мг/день 400 мг/день Обычная эффективная доза для взрослых 60–180 мг/день 400–1400 мг/день 200–400 мг/день 400–2000 мг/день Режим дозирования Один раз в день перед сном Два раза в день Детям: два раза в день; взрослым: возможно один раз в день Обычно 2–3 раза в день Редкие серьезные побочные эффекты  Тяжелая кожная сыпь (синдром Сти- венса – Джонсона*)  Угнетение костного мозга*  Печеночная недо- статочность  Тяжелая кожная сыпь (синдром Стивенса – Джон- сона*, токсический эпидермальный некролиз*)  Угнетение костного мозга*  Анемия и другие гемато- логические нарушения  Реакции гиперчувстви- тельности, в том числе тяжелая кожная сыпь (синдром Стивенса – Джонсона*)  Гепатит  Сонливость  Спутанность сознания Частые побочные эффекты  Сонливость  Гиперактивность у детей  Сонливость  Нарушение походки  Тошнота  Тошнота, рвота, запор  Тремор  Сонливость  Атаксия и невнятность речи  Подергивания мышц  Спутанность сознания  Летаргия  Седация  Тремор  Тошнота, диарея  Увеличение массы тела  Преходящее выпаде- ние волос (рост волос восстанавливается в течение 6 месяцев)  Нарушение функции печени Меры предосторожности  Не следует назна- чать фенобарбитал детям с умственной отсталостью или поведенческими нарушениями  Не следует назначать вальпроевую кислоту при беременности a Входит в состав межучрежденческого набора для оказания неотложной медицинской помощи (ВОЗ, 2011 г.) 41 ЭП И Рисунок ЭПИ 1 . Образец дневника припадков 3 . Последующее наблюдение » Обеспечьте регулярное последующее наблюдение:  В первые три месяца или до прекращения припадков не- обходимо запланировать посещения для последующего наблюдения с частотой как минимум раз в месяц.  После достижения контроля над припадками пациента необходимо осматривать раз в три месяца.  Более подробная информация по проведению после- дующего наблюдения приведена в разделе «Принципы лечения» (см. раздел «Общие принципы оказания помощи»). » Во время каждого посещения для последующего на- блюдения необходимо выполнять следующее:  Проверьте, насколько хорошо контролируются припадки: X Изучите дневник припадков, чтобы оценить, на- сколько хорошо они контролируются.  Оставьте прежнее назначение противоэпилептического препарата или измените его дозу в зависимости от сте- пени контроля над припадками. X Если при применении одного препарата в максималь- ной терапевтической дозе не удается достичь контро- ля над припадками или у пациента развились непере- носимые побочные эффекты, отмените этот препарат и назначьте другой. Постепенно повышайте дозу до достижения контроля над припадками. X Если припадки отмечаются очень редко, а дальнейшее повышение дозы может привести к тяжелым побоч- ным эффектам, текущая доза может быть приемлемой. X Если после поочередного применения двух препа- ратов не удалось достичь адекватного контроля над припадками, проконсультируйтесь со специалистом. Не следует одновременно назначать более одного противоэпилептического препарата.  При отсутствии припадков в течение последних двух лет рассмотрите вопрос отмены противоэпилептиче- ского препарата. X При отмене препарата постепенно снижайте дозу в течение нескольких месяцев с целью профилактики припадков вследствие развития синдрома отмены.  Привлекайте лиц, осуществляющих уход, к наблюдению за тем, насколько хорошо контролируются припадки.  Узнайте об особенностях образа жизни человека, про- ведите дополнительное психообразование и окажите поддержку пациенту и лицам, осуществляющим за ним уход, (см. п. 1 в разделе «Основной план действий по оказанию помощи» выше). Врезка  ЭПИ 1. Особые указания по ведению женщин с эпилепсией » Если женщина детородного возраста:  Назначьте фолиевую кислоту в дозе 5 мг/день для профилактики возможных пороков развития плода во время беременности. » Если женщина беременна:  Проконсультируйтесь со специалистом по вопросу лечения.  Порекомендуйте более частые посещения медицин- ских работников в антенатальном периоде и роды в стационаре.  После родов введите новорожденному препарат витамина K внутримышечно (в/м) в дозе 1 мг. » Решение о начале терапии противоэпилептическим пре- паратом во время беременности необходимо принимать совместно с женщиной. При этом необходимо оценить частоту и тяжесть припадков, а также возможный вред для плода как от припадков, так и от применения препа- рата. Если принято решение проводить медикаментоз- ную терапию, можно использовать фенобарбитал или карбамазепин. Не следует назначать вальпроевую кис- лоту и применять одновременно более одного препарата (полипрагмазия*). » Карбамазепин можно назначать кормящим матерям. Когда развился припадок Описание припадка (в том числе указать, какие части тела были вовлечены в процесс и как долго продолжался припадок) Какие препараты использовались Дата Время Вчера Сегодня Врезка ЭПИ 2 . Оценка состояния и необходимые действия в отношении человека, испытывающего судороги или находящегося без сознания после припадка При развитии припадка оценивать состояние человека и предпринимать необходимые действия следует одновременно. » Оценка припадка  Сохраняйте спокойствие. В большинстве случаев при- падки заканчиваются через несколько минут.  Проверьте состояние дыхательных путей, оцените состояние дыхания и кровообращения, в том числе измерьте артериальное давление, частоту дыхания и температуру тела.  Проверьте, нет ли признаков травмы головы или повреждения спинного мозга (например, расши- рение зрачков может свидетельствовать о серьезной травме головы).  Проверьте, нет ли ригидности затылочных мышц и лихорадки (признаки менингита). » Вопросы лицу, осуществляющему уход:  Когда начался припадок?  Случались ли у человека припадки раньше?  Была ли у него травма головы или шеи?  Есть ли у него какие-либо другие проблемы со здоровьем?  Принимал ли человек какие-либо лекарственные пре- параты, яды, алкоголь или наркотики?  Если пациент – женщина: если женщина беременна, то какой срок беременности? Были ли у женщины роды в течение последней недели? » Незамедлительно направьте пациента в стационар, если:  имеются любые признаки тяжелой травмы, шока* или нарушения дыхания;  человек мог получить серьезную травму головы или шеи: X Не двигайте шею пациента. X При перемещении пациента используйте методику «перекатывания бревна»*.  это беременная женщина (во второй половине бере- менности) или женщина, родившая ребенка менее недели тому назад;  есть подозрение на нейроинфекцию;  с момента начала припадка прошло более 5 минут. » Необходимые действия в случае развития припадка  Положите человека на бок в «восстановительное по- ложение» (см. рисунки A–D в разделе «Основной план действий по оказанию помощи» выше).  Если припадок не прекращается спонтанно через 1–2 минуты, как можно быстрее установите венозный катетер и начните медленно вводить глюкозу и бензо- диазепины (со скоростью 30 капель в минуту). X Если установить венозный катетер затруднительно, используйте ректальный путь для введения бензо- диазепинов. X Внимание: бензодиазепины могут угнетать дыха- ние. Начните оксигенотерапию, если это возможно, и оценивайте состояние дыхания через небольшие интервалы времени. X Доза глюкозы для детей: 2–5 мл/кг 10 % раствора глюкозы X Доза бензодиазепинов для детей: • диазепам ректально 0,2–0,5 мг/кг, или • диазепам внутривенно (в/в) 0,1–0,3 мг/кг, или • лоразепам в/в 0,1 мг/кг. X Доза глюкозы для взрослых: 25-50 мл 50 % раствора глюкозы X Доза бензодиазепинов для взрослых: • диазепам ректально 10–20 мг/кг, или • диазепам 10–20 мг в/в медленно, или • лоразепам в/в 4 мг. X Не вводите бензодиазепины внутримышечно (в/м).  Введите бензодиазепин повторно, если припадок не прекратился в течение 5–10 минут после первого введения.  Повторно введите ту же дозу, что и первый раз.  Не вводите бензодиазепины более двух раз. При необходимости введения бензодиазепина более двух раз человека следует направить в стационар.  Следующие признаки могут указывать на развитие эпилептического статуса: X припадки возникают с небольшим интервалом, и человек не приходит в себя в промежутках между припадками, или X двукратное введение бензодиазепинов не влияет на припадки, или X припадки продолжаются более 5 минут. » Незамедлительно направьте пациента в стационар, если:  есть подозрение на эпилептический статус (см. выше);  нет эффекта от первых двух введений бензодиазепинов;  после введения бензодиазепинов появились наруше- ния дыхания. 42 ЭП И 43 УО Умственная отсталостьУО Умственная отсталость9 характеризуется необратимыми ограничениями в нескольких областях ожидаемого умственного развития (т . е . в мышлении*, языковых умениях, двигательных и социальных навыках) . Эти ограничения присутствуют с рождения или появляются в детстве . При умственной отсталости нарушены обучаемость, повседневная деятельности и адаптация к новой среде . Людям с умственной отсталостью часто в большом объеме требуется уход и внимание . Они нередко сталкиваются с трудностями при получении доступа к медицинскому обслуживанию и образованию . В условиях хаоса во время чрезвычайных событий для таких людей особо высока вероятность подвергнуться жестокому обращению, остаться без должного внимания и попасть в опасные ситуации . Например, люди с умственной отсталостью с большей вероятностью могут неосознанно пойти в опасные районы . Более того, члены их семей и местных сообществ могут воспринимать их как обузу и при переезде оставлять на прежнем месте . В связи с этим в чрезвычайных гуманитарных ситуациях людям с умственной отсталостью требуется повышенное внимание . Этот раздел посвящен умственной отсталости средней, тяжелой и крайне тяжелой степени у детей, подростков и взрослых . 9 В проекте МКБ-11 для этого состояния предложен термин «расстройство умственного развития». » » » » 44 УО Вопрос 1 для оценки состояния: есть ли у человека умственная отсталость? » Оцените навыки и действия человека: Дети младшего возраста: оцените, полностью ли раз- витие ребенка соответствует возрастным нормам; при этом необходимо оценивать развитие по всем параме- трам (см. перечень ранних признаков отклонений во врезке УО 1). Лицам, осуществляющим уход, нужно задать следующие вопросы: XВаш ребенок ведет себя так же, как его сверстники? XЧто ваш ребенок умеет делать самостоятельно (сидеть, ходить, есть, одеваться, пользоваться горшком/туалетом)? XКак ваш ребенок общается с вами? Ребенок улыбается вам? Ребенок реагирует на свое имя? Как ребенок раз- говаривает с вами? Может ли ребенок попросить то, что он хочет? XКак ваш ребенок играет? Может ли ребенок хорошо играть со своими сверстниками? Дети более старшего возраста и подростки: спросите, ходят ли они в школу и, если да, как они справляются со школьными заданиями (изучением новой информации, чтением, письмом) и повседневными делами по дому. XТы ходишь в школу? Как ты учишься в школе? Ты можешь полностью выполнять школьные задания? Часто ли у тебя возникают трудности в школе из-за того, что ты не понимаешь, что надо делать, или не можешь выполнить это? Взрослые: спросите, работают ли они и, если да, как они справляются со своей работой и повседневными делами. XВы работаете? Какую работу вы выполняете? Часто ли у вас возникают трудности на работе из-за того, что вы не понимаете, что надо делать, или не можете выполнить это? Дети более старшего возраста, подростки и взрос- лые: спросите, в каком объеме другие люди помогают человеку в повседневной деятельности (например, в домашних делах, учебе, работе). » При выявлении отставания в развитии от сверстников исключите наличие состояний, поддающихся лечению, и обратимых состояний, которые могут имитировать умственную отсталость. Исключите нарушение зрения: XДети старше 6 месяцев: спросите у лица, осуществля- ющего уход, может ли ребенок делать следующее (при этом сами наблюдайте за ребенком): • может ли ребенок следить взглядом за движущимся предметом; • узнает ли ребенок знакомых людей; • может ли ребенок схватить предмет руками. XПри ответе «нет» хотя бы на один вопрос, сообщите лицу, осуществляющему уход, что у ребенка может быть нарушено зрение, и по возможности проконсуль- тируйтесь со специалистом. Исключите нарушение слуха: XДети старше 6 месяцев: спросите у лица, осуществля- ющего уход, может ли ребенок делать следующее (при этом сами наблюдайте за ребенком): • поворачивает ли ребенок голову, чтобы увидеть, кто говорит с ним из-за спины; • реагирует ли ребенок на громкие звуки; • лепечет ли ребенок (издает ли он звуки типа «та-та», «да-да», «ба-ба»). X При ответе «нет» хотя бы на один вопрос, сообщите лицу, осуществляющему уход, что у ребенка может быть нарушен слух, и по возможности проконсульти- руйтесь со специалистом. Исключите внешние проблемы: XДепрессивное расстройство средней или тяжелой сте- пени у матери или лица, осуществляющего основной уход за ребенком, (см. раздел ДЕП). XНедостаточная стимуляция (в младшем возрасте сти- муляция очень важна для развития головного мозга). • Кто регулярно общается и играет с ребенком? • Как вы или эти люди играете с ребенком? Как часто? • Как вы или эти люди общаетесь с ребенком? Как часто? Исключите неполноценное питание и другие формы дефицита питательных веществ и гормонов, в том числе дефицит йода* и гипотиреоз*. Исключите эпилепсию (см. раздел ЭПИ), которая может имитировать умственную отсталость или развиваться одновременно с ней. » Проведите лечение выявленных поддающихся лечению отклонений и повторно оцените состояние человека на предмет наличия умственной недостаточности. При подтверждении нарушения слуха или зрения предо- ставьте или порекомендуйте вспомогательные средства (очки, слуховой аппарат). При необходимости назначьте соответствующую терапию человеку, осуществляющему уход за ребенком, по поводу депрессивного расстройства. Научите человека, ухаживающего за ребенком, как создать более стимулирующую обстановку для малень- ких детей. См. документ Counsel the Family for Care for Development: Counselling Cards («Консультирование семьи по вопросам наблюдения за развитием ребенка: информационные карточки») (ЮНИСЕФ и ВОЗ, 2012 г.). При необходимости порекомендуйте участие в програм- мах развития детей в раннем возрасте (РДРВ). » Умственная отсталость может иметь место, если а) наблю- дается значительное отставание в развитии по сравнению с показателями возрастной нормы и человек испытывает трудности в обеспечении повседневных потребностей и б) состояния, поддающиеся лечению, и обратимые состо- яния были исключены или было проведено их лечение. Вопрос 2 для оценки состояния: если ли какие-либо поведенческие нарушения, связанные с этим состоянием? » Человек не слушает людей, осуществляющих за ним уход. » Отмечаются вспышки гнева. Когда человек расстроен, он ведет себя агрессивно и наносит себе повреждения. » Человек ест неорганические вещества. » Человек ведет беспорядочную половую жизнь, у него имеются другие нарушения поведения. 45 УО 1 . Проводите психообразование » Объясните самому человеку и лицу, осуществляющему за ним уход, что такое умственная отсталость. Людей с ум- ственной отсталостью не надо обвинять в том, что у них есть это отклонение. Цель беседы заключается в том, чтобы лица, осуществляющие уход, имели реальное представление о ситуации, были добры к подопечным и поддерживали их. » Проведите обучение родительским навыкам. Его цель – способствовать установлению хороших взаимоотноше- ний между ребенком и родителем или человеком, обе- спечивающим уход. Проведите обучение навыкам ухода, которые позволят уменьшить поведенческие проблемы. Лица, осуществляющие уход, должны понимать важность обучения их подопечного навыкам гигиены и ухода за собой (например, навыкам пользования горшком/туале- том, чистки зубов). Эти люди должны очень хорошо знать своего подопечно- го. Они должны знать, что может быть стрессовым факто- ром для человека, что приносит ему радость, что является причиной поведенческих нарушений и как их можно предупредить, в чем сильные и слабые стороны челове- ка, какой способ обучения подходит ему больше всего. Лица, осуществляющие уход, должны вести записи о повседневной жизни своего подопечного – о том, как он ест, играет, учится, работает и спит. Такие записи следует делать как можно регулярнее. Люди, осуществляющие уход за людьми с умственной отсталостью, должны поощрять своих подопечных за хорошее поведение, а при возникновении проблем с поведением не давать поощрения. Используйте сбалан- сированный подход к установлению дисциплины: XВ простой, краткой и понятной форме объясняйте человеку, что он должен делать, а не то, что он не должен делать. Разделите комплексные действия на несколько более простых этапов, так чтобы человек смог научиться и получать поощрение на каждом эта- пе (например, сначала научиться надевать брюки, а потом застегивать их). XКогда подопечный хорошо выполняет какое-то дей- ствие, поощряйте его за это. Отвлекайте подопечного от того, чем ему не следует заниматься. Однако такое отвлечение не должно быть приятным для подопечно- го и он не должен получать за него вознаграждение. XПри возникновении проблем с поведением НЕ приме- няйте угрозы и физическое наказание. » Объясните лицам, осуществляющим уход, что в целом их подопечные более подвержены физическому и сексуально- му насилию и в связи с этим им требуется больше внимания и защиты. » Объясните лицам, осуществляющим уход, что следует избегать институционализации, то есть передачи подо- печных в специализированные лечебные учреждения закрытого типа. 2 . Принимайте меры по обеспечению защиты человека на уровне местного сообщества » Узнайте, есть ли на местном уровне объединения, способ- ные оказать защиту (например, неформальные объедине- ния, местные НПО, правительственные и международные учреждения) и обратитесь к ним с просьбой оказать чело- веку соответствующую поддержку. 3 . Принимайте меры по привлечению человека к участию в жизни местного сообщества » Постарайтесь по мере возможности обеспечить обучение ребенка в обычной школе. Свяжитесь со школой, в которой учится ребенок, и узнай- те, есть ли возможности адаптировать для него условия обучения. В документе Inclusive Education of Children At Risk (INEE) («Инклюзивное обучение детей из групп риска») при- ведены простые советы относительно того, как это сделать. » Поощряйте участие человека в местных развлекательных общественных мероприятиях. » Узнайте о наличии программ реабилитации на уровне мест- ного сообщества* и поспособствуйте включению человека с умственной отсталостью в эти программы. 4 . Обеспечьте помощь и поддержку лицам, осуществляющим уход, в соответствии с «Принципами снижения стресса и укрепления социальной поддержки» (см . раздел «Общие принципы оказания помощи») 5 . Если возможно, направьте человека к специалисту для проведения дополнительной оценки и лечения возможных сопутствующих отклонений в развитии: » необратимые двигательные расстройства или церебраль- ный паралич*; » врожденные пороки развития, генетические отклонения или синдромы (например, синдром Дауна*). 46 УО Врезка УО 1: Основные этапы развития: ранние признаки отклонений, которые следует отслеживать К 1 МЕСЯЦУ  Плохое сосание груди или отказ от груди  Неактивные движения руками и ногами  Слабая реакция или отсутствие реакции на громкие звуки и яркий свет  Плач в течение длительного времени без явной причины  Рвота и диарея, которые могут приводить к обезвоживанию К 6 МЕСЯЦАМ  Скованность или затрудненные движения конечностями  Постоянные движения головой (это может указывать на инфекцию уха, которая при отсутствии лечения может приводить к потере слуха)  Слабая реакция или отсутствие реакции на звуки, знакомые лица или на грудь при кормлении  Отказ от груди и еды К 12 МЕСЯЦАМ  Отсутствие звуковой реакции на других людей  Отсутствие слежения взглядом за движущимися предметами  Апатия и слабая реакция на человека, осуществляющего уход  Снижение аппетита или отказ от еды К 2 ГОДАМ  Слабая реакция на других людей  Трудности в поддержании равновесия при ходьбе  Травмы и необъяснимые изменения в поведении (особенно при обеспечении ухода за ребен- ком)  Снижение аппетита К 3 ГОДАМ  Утрата интереса к играм  Частые падения  Трудности в обращении с мелкими предметами  Непонимание простых обращений  Неумение строить речь с использованием нескольких слов  Слабый интерес к еде или отсутствие такого интереса К 5 ГОДАМ  Проявление страха, гнева и жестокости во время игр с другими детьми, что может указывать на эмоциональные проблемы или применение насилия К 8 ГОДАМ  Трудности в установлении и поддержании дружеских отношений и участии в групповых видах деятельности  Уклонение от выполнения заданий и трудных дел без попыток или проявления беспомощности  Проблемы с выражением своих потребностей, мыслей и эмоций  Проблемы с концентрацией внимания на заданиях, пониманием и выполнением школьных за- даний  Чрезмерная агрессивность или стеснительность по отношению к друзьям и членам семьи Источник: ЮНИСЕФ, ВОЗ, ЮНЕСКО, ЮНФПА, ПРООН, ЮНЭЙДС, ВПП и Всемирный банк (2010 г.) 6 . Последующее наблюдение » Составьте план посещений в соответствии с «Принципами лечения» (см. раздел «Общие принципы оказания помо- щи») и проводите последующее наблюдение в соответ- ствии с этим планом. 47 ВЕ Щ Пагубное употребление алкоголя и наркотических средств ВЕЩ Употребление алкоголя и наркотиков (например, опиатов* [например, героина], производных конопли*, амфетаминов*, ката*, разных рецептурных препаратов, таких как бензодиазепины* и трамадол*) может быть причиной разных проблем . К ним относятся синдром отмены (соматиче- ские и психические симптомы, появляющиеся при прекращении или значительном сокращении употребления этих веществ), зависимость* и пагубное употребление (ухудшение физического и психического здоровья и (или) общего благополучия) . Употребление алкоголя и наркотиков являет- ся пагубным, когда оно становится причиной соматических и психических расстройств, поведения, связанного с риском для здоровья, семейных проблем и проблем в отношениях с другими людьми, сексуального и физического насилия, несчастных случаев, надругательства над детьми и безнад- зорности детей, финансовых трудностей и других проблемы с обеспечением защиты . В чрезвычай- ных гуманитарных ситуациях распространенность пагубного употребления алкоголя и наркоти- ков может возрастать, так как в этих условиях взрослые и подростки занимаются самолечением*, чтобы справиться со стрессом, утратами и болью . При чрезвычайных обстоятельствах снабжение алкоголем и наркотиками может быть прекращено . В результате этого у лиц, которые принимали эти вещества в относительно высоких дозах в течение длительного времени, неожиданно развиваются симптомы угрожающего жизни синдро- ма отмены . Особенно это относится к алкоголю . Этот раздел посвящен пагубному употреблению алкоголя и наркотических средств . В нем также приведена информация о синдроме отмены алкоголя, угрожающем жизни (см. врезку ВЕЩ 1) . Дру- гие аспекты употребления алкоголя и наркотиков освещены в соответствующих разделах полной версии «Руководства mhGAP по принятию мер в отношении психических и неврологических рас- стройств» . Информация о проведении оценки состояния и необходимых действиях в отношении людей с синдромом отмены алкоголя, угрожающим жизни, приведена во врезке ВЕЩ 1 на стр. 50. » » » » 48 ВЕ Щ Вопрос для оценки состояния: нарушено ли физическое и психическое здоровье и (или) общее благополучие вследствие употребления алкоголя или наркотиков? » Узнайте об употреблении алкоголя и наркотиков, не выражая при этом своего мнения. » Узнайте следующую информацию: В каком объеме человек употребляет алкоголь (наркотики) и как он это делает XВы употребляете алкоголь? Если да, то в каком виде? Сколько стандартных порций вы выпиваете в день, в неделю? XПринимаете ли вы какие-либо назначенные врачом снотворные препараты, препараты для снятия тре- воги, болеутоляющие препараты в таблетках? Какие это препараты? Сколько таблеток вы принимаете в день, в неделю? XУпотребляете ли вы какие-либо запрещенные нарко- тики? Какие это наркотики? Как вы их употребляете – внутрь, инъекционно, путем вдыхания? В каком объеме и сколько раз в день, в неделю вы их употребляете? Побуждение к употреблению алкоголя и наркотиков XЧто вызывает у вас желание употреблять алкоголь или наркотики? Причинение вреда себе и окружающим XПроблемы со здоровьем и травмы в результате упо- требления алкоголя и наркотиков • Были ли у вас какие-либо отклонения со стороны здоровья после того, как вы начали употреблять алкоголь или наркотики? • Получали ли вы травмы в то время, когда находились под влиянием алкоголя или наркотиков? XПродолжение употребления алкоголя или наркотиков, несмотря на рекомендации прекратить употребление этих веществ: • во время беременности или кормления грудью; • после того, как человек узнал, что у него есть патология желудка или печени, вызванная употреблением алкоголя или наркотиков; • во время лечения препаратами, взаимодействие которых с алкоголем и наркотиками приводит к опасным последствиям, такими как седативные средства, анальгетики и противотуберкулезные препараты. XСоциальные проблемы в результате употребления алкоголя и наркотиков: • Финансовые проблемы и проблемы с законом • Были ли у вас когда-либо финансовые проблемы, нарушали ли вы когда-нибудь законы из-за употребления алкоголя или наркотиков? • Проблемы, связанные с профессиональной деятельностью • Были ли случаи, когда из-за употребления алкоголя или наркотиков вы лишались работы или плохо выполняли свою работу? • Проблемы с осуществлением ухода за детьми и другими иждивенцами • Возникали ли у вас трудности в обеспечении ухода за своими детьми или другими членами семьи из-за употребления алкоголя или наркотиков? • Насилие в отношении других людей • Причиняли ли вы вред другим людям во время употребления алкоголя или наркотиков? • Проблемы во взаимоотношениях с другими людьми, проблемы с супругом • Были ли у вас проблемы с вашим партнером из-за того, что вы употребляли алкоголь или наркотики? » Проведите быстрое общее физикальное обследование на предмет наличия признаков хронического употребления алкоголя и наркотиков: Кровотечение из органов желудочно-кишечного тракта: Xболь в животе; Xкровь в рвотных массах; Xкровь в кале и черный кал. Заболевание печени: X тяжелое: желтуха, асцит*, увеличение и уплотнение печени и селезенки, печеночная энцефалопатия*. Истощение, выраженное снижение массы тела. Признаки инфекции, связанной с употреблением нарко- тиков (например, ВИЧ, гепатит B или C, инфекции кожи в месте инъекций или туберкулез). » Оценивайте одновременно наличие признаков употребле- ния и алкоголя, и наркотиков, так как часто они сочетаются. 49 ВЕ Щ 1 . Принимайте меры по устранению неблагоприятных эффектов употребления алкоголя или наркотиков » Окажите необходимую медицинскую помощь для устра- нения соматических последствий пагубного употребления алкоголя или наркотиков. » Назначьте лечение сопутствующих психических заболева- ний, таких как депрессивное расстройство средней или тяже- лой степени, ПТСР и психоз (см. разделы ДЕП, ПТСР, ПСИ). » Примите меры по устранению социальных последствий, требующих неотложных мер (например, при применении насилия над человеком, например насилия, совершаемого на основании полового признака, свяжитесь со службами защиты). 2 . Оцените мотивацию человека к сокращению употребления алкоголя или наркотиков или полному отказу от них » Выясните, считает ли человек употребление алкого- ля или наркотиков проблемой и, если да, готов ли он что-либо делать для ее решения Считаете ли вы, что у вас может быть проблема, свя- занная с употреблением алкоголя или наркотиков? Думали ли вы о том, чтобы сократить употребление алко- голя или наркотиков или полностью отказаться от них? Пытались ли вы раньше сократить потребление алкого- ля или наркотиков или полностью отказаться от них? 3 . Побуждайте человека к сокращению употребления алкоголя или наркотиков или полному отказу от них » Начните короткую мотивационную беседу о пагубном употреблении этих веществ: Спросите у человека, в чем он видит пользу и вред от употребления алкоголя и наркотиков. Не высказывайте своего мнения, но постарайтесь понять мотивацию чело- века к употреблению алкоголя и наркотиков. XКакие приятные ощущения вы получаете от употре- бления алкоголя и наркотиков? XВидите ли вы какие-либо отрицательные стороны в употреблении алкоголя или наркотиков? XСожалели ли вы когда-либо об употреблении алкоголя или наркотиков? Поставьте под сомнение преувеличенное восприя- тие пользы от употребления алкоголя или наркотиков. Например, если человек употребляет алкоголь или наркотики, чтобы забыть жизненные трудности, задайте следующие вопросы: XХорошо ли это – просто забыть о проблеме? Поможет ли это устранить проблему? Обратите внимание человека на некоторые отрица- тельные стороны употребления алкоголя и наркотиков, которые человек может недооценивать. XСколько денег вы тратите на покупку алкоголя или наркотиков? В неделю? В месяц? В год? Что еще вы могли бы сделать с этими деньгами? Расскажите о вредном воздействии алкоголя и нар- котиков как в краткосрочной, так и в долгосрочной перспективе. XУпотребление алкоголя и наркотиков может приво- дить к серьезным заболеваниям, в том числе психиче- ским отклонениям, травмам и развитию пристрастия. Согласитесь с тем, что отказаться от употребления алкоголя или наркотиков трудно. Покажите человеку, что вы хотите поддержать его. Поспособствуйте тому, чтобы человек сам решил, надо ли ему отказываться от употре- бления алкоголя или наркотиков. Если человек не готов сократить употребление алко- голя или наркотиков или полностью отказаться от них, проявите уважение к его решению. Попросите человека прийти в другой раз, чтобы вы могли продолжить беседу. » Проводите описанные выше краткие мотивационные бесе- ды в течение нескольких встреч. 4 . Обсудите разные способы сокращения употребления алкоголя или наркотиков или полного отказа от них » Обсудите следующие варианты: Посоветуйте человеку не хранить алкоголь и наркотики дома. Посоветуйте ему не ходить вблизи мест, в которых люди могут употреблять алкоголь или наркотики. Порекомендуйте обратиться за поддержкой к друзьям и лицам, осуществляющим уход. Попросите людей, осуществляющих уход, сопровождать человека во время следующих посещений. Побудите человека участвовать в общественных меро- приятиях, не предполагающих употребление алкоголя и наркотиков. » Рассмотрите возможность направления человека в группу взаимопомощи людей, употребляющих алкоголь или нарко- тики, если она существует. » Если человек согласен отказаться от употребления алкого- ля или наркотиков, сообщите ему о возможности разви- тия преходящих симптомов синдрома отмены (которые отмечаются в течение менее 7 дней). Опишите эти симпто- мы (например, тревога и тревожное возбуждение после прекращения приема опиатов, бензодиазепинов и алкого- ля). Посоветуйте человеку повторно обратиться в лечебное учреждение, если симптомы будут иметь тяжелую форму. 50 ВЕ Щ 5 . Предложите психосоциальную поддержку в соответствии с рекомендациями в разделе «Принципы снижения стресса и укрепления социальной поддержки» (см. раздел «Общие принципы оказания помощи») » Воздействуйте на психосоциальные факторы, вызывающие у человека стресс в настоящий момент. » Окажите дополнительную социальную поддержку. » Научите человека, как справляться со стрессом. 6 . Предложите регулярное последующее наблюдение » Продолжайте предлагать поддержку, беседовать и работать с пациентом и лицами, осуществляющими за ним уход, в направлении снижения употребления алкоголя и наркоти- ков или полного отказа от них. Составьте план регулярных посещений (см. «Принципы лечения» в разделе «Общие принципы оказания помощи») и проводите последующее наблюдение в соответствии с этим планом. Врезка ВЕЩ 1 . Информация о проведении оценки состояния и необходимых действиях в отношении людей с синдромом отмены алкоголя, угрожающим жизни . Типичные жалобы пациента с синдромом отмены алкоголя, угрожающим жизни, при первом контакте » Тревожное возбуждение, выраженное беспокойство » Спутанность сознания или галлюцинации* (человек видит, слышит или ощущает то, чего в действительности нет) » Судороги или припадки » Повышение артериального давления (> 180/100 мм рт. ст.) и (или) частоты сердечных сокращений (> 100 уд./мин.) Оценка состояния при синдроме отмены алкоголя, угрожающем жизни Вопрос 1 для оценки состояния: есть ли у челове- ка синдром отмены алкоголя? » Исключите другие причины, которые могли бы объяс- нить наличие имеющихся симптомов, а при их наличии примите соответствующие меры. К таким причинам относятся: малярия, ВИЧ/СПИД, другие инфекции, травмы головы, нарушения обмена веществ* (например, гипоглике- мия*, гипонатриемия*), печеночная энцефалопатия, гипертиреоз*, инсульт, употребление наркотиков (например, амфетаминов), подтвержденный психоз или эпилепсия в анамнезе. » После исключения вышеперечисленных причин соберите информацию об употреблении алкоголя, задав челове- ку и лицам, осуществляющим уход, следующие вопросы: Употребляет ли человек алкоголь? Когда он последний раз употреблял алкоголь? Как много алкоголя он обычно употребляет? » На синдром отмены алкоголя может указывать появление симптомов после прекращения регулярного употребле- ния алкоголя или употребления его в большом количе- стве. Обычно симптомы появляются через 1–2 дня после употребления последней порции. При наличии припадков или галлюцинаций и отсут- ствии подозрения на синдром отмены алкоголя оцени- те состояние человека на предмет наличие эпилепсии (см. раздел ЭПИ) или психоза (см. раздел ПСИ). Вопрос 2 для оценки состояния: если у человека есть синдром отмены алкоголя, угрожает ли это состояние жизни? » Оцените состояние человека на предмет наличия угро- жающих жизни отклонений: судороги/припадки (обычно в течение 48 часов); проявления делирия* (обычно в течение 96 часов); Xострое состояние спутанности сознания, дезориен- тация; X галлюцинации. » Оцените, насколько высок риск развития угрожающих жизни отклонений (судорог или делирия) в течение следующих одного-двух дней: наличие угрожающих жизни отклонений (судорог или делирия) в прошлом или наличие тяжелых проявлений синдрома отмены в настоящее время: Xкрайнее тревожное возбуждение, выраженная раздражительность, выраженное беспокойство; Xизбыточное потоотделение, тремор кистей; Xповышение артериального давления (> 180/100 мм рт. ст.) и (или) частоты сердечных сокращений (> 100 уд./мин.). При подозрении на делирий вследствие развития синдрома отмены алкоголя действуйте в соответствии с планом неотложных действий при угрожающем жизни синдроме отме- ны алкоголя (см . ниже) и организуйте доставку пациента в ближайший стационар с соответствующим сопровождением . 51 ВЕ Щ План неотложных действий при угрожающем жизни синдроме отмены алкоголя 1. Для устранения проявлений синдрома отмены алкоголя сразу же назначьте диазепам (см. таблицу ВЕЩ 1) » Доза диазепама зависит от степени привыкания* ор- ганизма человека к этому препарату, степени тяжести симптомов синдрома отмены и наличия сопутствующих соматических расстройств. Дозу следует корректировать в зависимости от на- блюдаемого эффекта. Правильная доза обеспечивает небольшой седативный эффект. XСлишком высокая доза может вызвать чрезмерный седативный эффект и угнетение дыхания. Кон- тролируйте частоту дыхания и уровень седации (например, степень сонливости) через небольшие интервалы времени. XПри введении препарата в недостаточной дозе существует риск развития припадков или делирия. » Наблюдайте за проявлениями синдрома отмены через небольшие интервалы времени (каждые 3–4 часа). Про- должайте терапию диазепамом до исчезновения симпто- мов (обычно необходимо 3–4 дня, но не более 7 дней). » При развитии абстинентного судорожного припадка НЕ ИСПОЛЬЗУЙТЕ противоэпилептические препараты. Продолжайте терапию диазепамом. » Симптомы делирия, такие как спутанность сознания, тревожное возбуждение и галлюцинации, могут сохра- няться в течение нескольких недель после исчезновения других проявлений синдрома отмены. В таких случаях рассмотрите возможность применения нейролепти- ков, например галоперидола в дозе 2,5–5 мг внутрь 3 раза в день, до ослабления симптоматики (спутанности сознания, тревожного возбуждения или галлюцинаций). Иногда галлюцинации и спутанность сознания исчезают только через несколько недель. Не допускайте развития чрезмерного седативного эффекта. » По возможности поместите человека в тихое хорошо ос- вещенное помещение, в котором нет внешних раздражи- телей. Постарайтесь обеспечить некоторое освещение в помещении даже в ночное время, чтобы предотвратить падения в случае, если человек решит ночью встать с постели. Чтобы предотвратить падения, можно также рассмотреть вариант размещения человека на матрасе на полу. Если возможно, попросите человека, осущест- вляющего уход, остаться с пациентом и наблюдать за его состоянием. По возможности старайтесь не ограничи- вать свободу пациента. 2. Примите меры по устранению истощения » Назначьте витамин B1 (тиамин) в дозе 100 мг/день внутрь в течение 5 дней. » Оцените состояние человека на предмет наличия при- знаков недоедания и при их наличии примите соответ- ствующие меры. 3. Обеспечьте поддержание нормального водного баланса » По возможности начните в/в инфузионную терапию. » Расскажите человеку о необходимости приема жидкости (не менее 2–3 литров в день). 4. После устранения синдрома отмены, угрожающего жизни, оцените признаки пагубного употребления алкоголя или наркотиков и назначьте соответству- ющее лечение (см. основную часть этого раздела) Таблица ВЕЩ 1 . Применение диазепама при синдроме отмены алкоголя, угрожающем жизни a Входит в состав межучрежденческого набора для оказания неотложной медицинской помощи (ВОЗ, 2011 г.) Диазепамa Начальная доза 10–20 мг до 4 раз в день в течение 3–7 дней Последующие дозы При ослаблении симптоматики начните постепенно снижать дозу и (или) частоту приема. Контролируйте состояние пациента через небольшие интервалы времени, так как люди могут по-разному реагировать на этот препарат Путь введения Внутрь Тяжелые побочные эффекты (редко) Угнетение дыхания*, выраженное нарушение сознания Внимание: контролируйте частоту дыхания и уровень седации через небольшие интервалы времени Частые побочные эффекты Сонливость, амнезия, нарушение сознания, мышечная слабость Внимание: не вводите препарат повторно, если человек находится в сонливом состоянии Меры предосторожности при применении в особых группах Пожилым людям следует назначать четверть или половину рекомендуемой дозы Не назначайте препарат людям с нарушениями дыхания

53 СУ И Суицид СУИ В чрезвычайных гуманитарных ситуациях у людей часто развиваются психические нару- шения, острый эмоциональный стресс, и появляется ощущение беспомощности . Эти про- блемы могут стать причиной суицида* или самоповреждения* . Некоторые медицинские работники ошибочно думают, что вопросы о суициде могут подтолкнуть человека к по- пытке самоубийства . Это не так . Напротив, разговоры о суициде часто уменьшают тревогу, вызванную мыслями о самоубийстве, помогают человеку почувствовать, что его понима- ют, и дают больше возможностей для дальнейшего обсуждения проблемы . При наличии у взрослых и подростков любого из описанных в данном руководстве психических и не- врологических расстройств, а также расстройств, связанных с употреблением наркотиков и других веществ (ПНВ), существует риск суицида или самоповреждения . » » » 54 СУ И Врезка СУИ 1 . Как разговаривать о суициде и самоповреждении 1 . Создайте безопасную и уединенную обстановку, чтобы помочь человеку поделиться своими мыслями . » Не осуждайте человека за его желание покончить жизнь самоубийством. » Предложите человеку поговорить наедине или в присут- ствии других людей, которых он выберет. 2 . Задайте ряд вопросов, формулируя их таким образом, чтобы любой ответ на предыдущий вопрос естественным образом подводил разговор к следующему вопросу . Например: » [Начните с вопроса о текущей ситуации.] Как вы себя чувствуете? » [Покажите, что вы понимаете чувства человека.] Вы выглядите грустным/расстроенным. Я бы хотел задать вам несколько вопросов об этом. » Как вы видите свое будущее? Каковы ваши надежды на будущее? » Некоторые люди с подобными проблемами говорили мне, что они не видят смысла жить. Когда вы ложитесь спать, есть ли у вас желание не просыпаться утром? » У вас бывают мысли о том, чтобы нанести себе вред? » Вы когда-нибудь планировали покончить с жизнью? » Если да, как вы планируете сделать это? » Есть ли у вас средства для того, чтобы покончить с жизнью? » Вы думали о том, когда сделать это? » Предпринимали ли вы попытку покончить с жизнью? 3 . Если человек выражает суицидальные идеи, » сохраняйте спокойствие и покажите, что вы поддержи- ваете его; » не давайте ложных обещаний. Вопрос 1 для оценки состояния: совершал ли человек попытку суицида или самоповреждения в недавнем прошлом? » Оцените состояние на предмет наличия следующих откло- нений: признаков отравления, алкогольной или лекарственной интоксикации, передозировки лекарственных веществ или других признаков самоповреждения; признаков, требующих срочного медицинского вме- шательства: Xкровотечение из нанесенной себе раны, Xпотеря сознания, Xкрайне выраженная летаргия. Вопрос 2 для оценки состояния: есть ли непосредственный риск совершения суицида или самоповреждения? » Спросите человека и лица, осуществляющего уход за ним, о следующем: мыслях о совершении суицида и соответствующих пла- нах (в настоящее время и в предыдущем месяце); актах самоповреждения в предыдущем году; доступе к средствам для совершения суицида (например, пестицидам, веревкам, оружию, ножам, рецептурным препаратам и наркотикам). » Оцените состояние человека на предмет наличия следую- щих отклонений: сильный эмоциональный стресс или ощущение беспо- мощности; агрессивное поведение или крайнее тревожное воз- буждение; замкнутость или нежелание общаться. » На наличие непосредственного риска совершения суици- да или самоповреждения указывает соответствие одному из следующих критериев: наличие суицидальных мыслей, планов или действий в настоящее время; наличие мыслей или планов о самоповреждении в предыдущем месяце или совершение актов самопо- вреждения в предыдущем году (для человека, который в момент оценки крайне возбужден, агрессивен, находит- ся в стрессовом состоянии или отказывается от общения). Вопрос 3 для оценки состояния: присутствуют ли сопутствующие состояния, связанные с суицидом или самоповреждением? » Оцените состояние человека на предмет наличия возмож- ных сопутствующих состояний и назначьте лечение: хронический болевой синдром или инвалидность (например, вследствие недавно полученных травм в условиях чрезвычайной гуманитарной ситуации); депрессивное расстройство средней или тяжелой степени (см. раздел ДЕП); психоз (см. раздел ПСИХ); пагубное употребление алкоголя и наркотических средств (см. раздел ВЕЩ); посттравматическое стрессовое расстройство (см. раздел ПТСР); острый эмоциональный стресс (см. разделы ОСР, ГОРЕ, ПРОЧ). 55 СУ И 1 . Если человек предпринял попытку суицида, окажите необходимую медицинскую помощь и психосоциальную поддержку и обеспечьте контроль над его состоянием » Окажите медицинскую помощь: Оказывайте помощь людям, нанесшим себе поврежде- ния, с таким же вниманием, уважением, как и другим пациентам, обеспечивая при этом такую же степень конфиденциальности. Не наказывайте этих людей. Проведите соответствующее лечение травмы или отрав- ления. XРекомендации по оказанию помощи при остром отравлении пестицидами приведены в документе Clinical Management of Acute Pesticide Intoxication («Клиническое руководство по ведению пациентов с острым отравлением пестицидами») (ВОЗ, 2008 г.). В случае передозировки лекарственного препарата, если необходимость в применении препарата все еще присутствует, назначьте альтернативный наиболее без- опасный препарат. По возможности назначайте новый препарат короткими курсами (например, от нескольких дней до недели), чтобы предотвратить повторные случаи передозировки. » При сохранении непосредственного риска совершения суицида постоянно контролируйте состояние человека (см. рекомендации ниже). » Предложите психосоциальную поддержку (см. рекоменда- ции ниже). » По возможности проконсультируйтесь со специалистом в области психического здоровья. 2 . Если присутствует непосредственный риск совершения суицида или самоповреждения, контролируйте состояние человека и окажите ему психосоциальную поддержку » Контролируйте состояние человека: Создайте безопасную обстановку, в которой человек будет чувствовать поддержку. Удалите все средства, которые можно использовать для самоповреждения или самоубийства и по возможности поместите человека в отдельное тихое помещение. Однако не оставляйте человека одного. Проконтролируйте, чтобы человек все время находился в присутствии лица, осуществляющего уход, или кого-либо из сотрудников. В обычном режиме НЕ ПОМЕЩАЙТЕ людей в палаты терапевтического профиля для предупреждения суици- дальных действий. Сотрудники больницы могут не иметь достаточно возможностей для контроля над состоянием человека с суицидальными наклонностями. Однако, если госпитализация в палату терапевтического профи- ля необходима для лечения соматических последствий самоповреждения, тщательно контролируйте состояние человека для предупреждения повторных актов самопо- вреждения в больнице. Независимо от места нахождения человека обеспечьте наблюдение за ним 24 часа в сутки до исчезновения непосредственного риска суицида. » Предложите психосоциальную поддержку: НЕ начинайте с предложения человеку возможных ре- шений его проблем. Вместо этого постарайтесь вселить надежду. Например, так: XМногие люди, которые находились в подобных ситу- ациях – чувствовали себя беспомощными, хотели умереть – потом обретали надежду, и их ощущения улучшались со временем. Помогите человеку найти смысл продолжать жить. Постарайтесь вместе найти решения проблем. При сохранении непосредственного риска суицида привлекайте лиц, осуществляющих уход за человеком, его друзей и других доверенных лиц, а также ресурсы местного сообщества для наблюдения за человеком и оказания ему поддержки. Объясните им необходимость круглосуточного наблюдения за человеком. Проконтро- лируйте, чтобы они составили четкий реальный план (на- пример, решив, кто в какое время суток будет наблюдать за человеком). Предложите дополнительную психосоциальную под- держку, как описано в разделе «Принципы снижения стресса и укрепления социальной поддержки» (см. «Общие принципы оказания помощи»). » По возможности проконсультируйтесь со специалистом в области психического здоровья. 3 . Обеспечьте помощь и поддержку лицам, осуществляющим уход, в соответствии с «Принципами снижения стресса и укрепления социальной поддержки» (см. раздел «Общие принципы оказания помощи») 4 . Поддерживайте регулярную связь с человеком и регулярно проводите последующее наблюдение » Обязательно составьте четкий план посещений для после- дующего наблюдения и убедитесь, чтобы лица, осущест- вляющие уход за человеком, осознали свою ответствен- ность за выполнение этого плана (см. «Принципы лечения» в разделе «Общие принципы оказания помощи»). » Регулярно поддерживайте связь с человеком (например, по телефону, с помощью текстовых сообщений или посещений на дому). » В первое время проводите наблюдение через небольшие интервалы времени (например, еженедельно в течение первых двух месяцев), а по мере улучшения состояния че- ловека снижайте частоту контактов (каждые 2–4 недели). » Продолжайте наблюдение, пока сохраняется риск суицида. При каждом контакте в обычном порядке оценивайте нали- чие суицидальных мыслей и планов.

57 П РО Ч Прочие значимые жалобы, связанные с психическим здоровьем ПРОЧ В этом руководстве описаны основные психические, неврологические расстройства и расстройства, связанные с употреблением наркотиков и других веществ (ПНВ), связанные с чрезвычайными гуманитарными ситуациями . Однако это не все возможные расстройства психического здоровья . Поэтому в этом разделе приведены основные рекомендации по оказанию поддержки на начальном этапе взрослым, подросткам и детям с жалобами, связанными с психическим здоровьем, не описанными в других разделах данного руководства . К прочим жалобам, связанным с психическим здоровьем, относятся: а) различные соматические симптомы при отсутствии соматических отклонений, которые могли бы послужить их причиной, и б) изменения настроения и поведения, которые вызывают обеспокоенность, но не полностью соответствуют критериям состояний, описанных в других разделах данного руководства . Это могут быть жалобы, свидетельствующие о депрессивном расстройстве легкой степени и ряде других состояний в субклинической форме . Прочие жалобы, связанные с психическим здоровьем, считаются значимыми, если они нарушают повседневную жизнь человека или служат причиной обращения за помощью . 58 П РО Ч Вопрос 1 для оценки состояния: есть ли у человека какое-либо соматическое состояние, наличие которого может полностью объяснить существующие симптомы? » Сначала проведите общее физикальное обследование, а затем необходимые дополнительные обследования. » Примите необходимые меры по устранению выявленной соматической причины, затем повторно оцените состояние человека, чтобы выяснить, сохраняются ли первоначальные симптомы. Вопрос 2 для оценки состояния: присутствует ли у человека какое-либо из состояний ПНВ, описанных в других разделах данного руководства? » Исключите следующее: Выраженные симптомы острого стресса (см. раздел ОСР) XОсновные проявления: • потенциально травмирующее событие в предыду- щем месяце; • появление симптомов после этого события; • обращение за помощью с целью облегчения сим- птомов или значительное нарушение повседневной жизни из-за наличия этих симптомов. Выраженные проявления горя (см. раздел ГОРЕ) XОсновные проявления: • появление симптомов после большой утраты; • обращение за помощью с целью облегчения сим- птомов или значительное нарушение повседневной жизни из-за наличия этих симптомов. Депрессивное расстройство средней или тяжелой степени (см. раздел ДЕП) XОсновные проявления (сохраняющиеся в течение как минимум двух недель): • устойчиво подавленное настроение; • резко сниженный интерес или степень удовольствия от выполняемых дел, особенно тех, которые раньше доставляли радость; • значительное нарушение повседневной жизни из-за наличия этих симптомов. Посттравматическое стрессовое расстройство (см. раздел ПТСР) XОсновные проявления: • потенциально травмирующее событие, произошед- шее более месяца назад; • повторяющиеся кошмарные сны, яркие повторные пе- реживания* или навязчивые воспоминания* о событи- ях, сопровождающиеся сильным страхом или ужасом; • целенаправленное избегание факторов, напоминаю- щих о событии; • повышенное чувство опасности (избыточная обеспокоенность и настороженность в отношении опасности или резкая реакция на громкие звуки или неожиданные движения); • значительное нарушение повседневной жизни из-за наличия этих симптомов. Пагубное употребление алкоголя и наркотиков (см. раздел ВЕЩ) XОсновные проявления: • употребление алкоголя и наркотиков, причиняющее вред самому человеку (или) другим людям. Суицид, самоповреждение (см. раздел СУИ) XОсновные проявления: • акты самоповреждения в настоящее время; наличие суицидальных мыслей и планов в настоящее время или • мысли, планы о самоповреждении и акты самопо- вреждения в недавнем прошлом (для человека, который в момент оценки крайне возбужден, нахо- дится в стрессовом состоянии, замкнут или отказы- вается от общения). » При подозрении на любое из этих состояний проводите оценку и лечение с учетом рекомендаций в соответствую- щем разделе. » Если 1) соматические причины исключены, 2) выше- перечисленные расстройства ПНВ исключены и 3) человек обратился за помощью с целью облегчения симптомов или данные симптомы значительно наруша- ют повседневную жизнь человека, считается, что имеют место прочие значимые жалобы, связанные с психиче- ским здоровьем. Обычно для исключения соматических причин и выше- перечисленных расстройств ПНВ требуется несколько посещений. Вопрос 3 для оценки состояния: в отношении подростков: есть ли у человека нарушение поведения? » Побеседуйте с подростком и лицами, осуществляю- щими уход за ним, для того чтобы выяснить, имеют ли место стойкие или вызывающие опасения отклонения в поведении. Некоторые примеры: неспровоцированное проявление агрессии; употребление наркотиков; запугивание сверстников или проявление жестокости по отношению к ним; вандализм; сексуальное поведение, связанное с риском. » Если у подростка имеются отклонения в поведении, задайте дополнительные вопросы: о сильных стрессовых факторах в жизни подростка в про- шлом и в настоящем (например, сексуальное насилие); об отношении родителей (непоследовательные или стро- гие правила дисциплины, недостаточная эмоциональ- ная поддержка, недостаточный контроль, психическое расстройство у лица, осуществляющего уход); о том, чем подросток занимается большую часть време- ни. Задайте следующие вопросы: X (если подросток работает или учится в школе) Как ты проводишь время после работы/школы? Есть ли у тебя какие-либо регулярные занятия? X Часто ли ты скучаешь? Что ты делаешь, когда тебе скучно? 59 П РО Ч НЕ назначайте лекарственные препараты по поводу прочих значимых жалоб, связанных с психическим здоровьем (за исключением случаев, когда это рекомендовано специалистом) . НЕ назначайте инъекции витаминов и другое неэффективное лечение. 1 . Во всех случаях (людям с эмоциональными, соматическими и поведенческими отклонениями) окажите базовую психосоциальную поддержку в соответствии с «Принципами снижения стресса и укрепления социальной поддержки» (см. раздел «Общие принципы оказания помощи») » Воздействуйте на психосоциальные факторы, вызывающие у человека стресс в настоящий момент. » Окажите дополнительную социальную поддержку. » Научите человека, как справляться со стрессом. 2 . При отсутствии соматического состояния, которое могло бы полностью объяснить тот или иной физический симптом, признайте наличие этих симптомов и по возможности дайте объяснения » НЕ назначайте дополнительные лабораторные исследова- ния, за исключением случаев, когда для этого есть четкие медицинские показания (например, отклонения основ- ных показателей жизнедеятельности). Назначение ненужных клинических исследований может еще больше укрепить человека во мнении, что у него есть соматическое расстройство. При проведении клинических исследований могут раз- виваться побочные эффекты. » Сообщите человеку, что у него не обнаружено никакого серьезного заболевания. Сообщите, что клиническое об- следование и лабораторные анализы не выявили никаких отклонений. Мы не обнаружили никакого серьезного физического нарушения. На данный момент я не вижу оснований для дополнительных исследований. » Если человек настаивает на проведении дополнительных исследований, вы можете сказать следующее: Проведение исследований без необходимости может причинить вред, так как может стать причиной необо- снованного беспокойства и побочных эффектов. » Признайте, что симптомы реально существуют и что действительно важно устранять те из них, которые достав- ляют серьезные проблемы. » Попросите человека дать собственное объяснение имею- щимся симптомам. Это может помочь найти причину, уста- новить доверительные отношения с человеком и улучшить соблюдение режима лечения. » Объясните, что эмоциональные страдания/стресс часто со- провождаются физическими ощущениями (болью в животе, напряжением мышц и т. д.). Спросите, может ли быть связь между эмоциями человека или испытываемым им стрессом и имеющимися симптомами, и обсудите этот вопрос. » Поощряйте продолжение повседневных занятий или посте- пенное возвращение к ним. » Кроме этого, следуйте рекомендациям в разделе «Принци- пы снижения стресса и укрепления социальной поддержки» (см. «Общие принципы оказания помощи»). 3 . В отношении подростков с нарушениями поведения » Внимательно выслушайте собственное мнение подростка о проблеме (предпочтительнее в отсутствии лиц, осущест- вляющих уход). » Проведите психообразование для подростка и лиц, осу- ществляющих уход за ним. Объясните следующее: Проблемы с поведением иногда возникают у подростков, когда они злятся или беспокоятся или когда им скучно или грустно. Несмотря на такое поведение, им нужна постоянная помощь и поддержка. Лица, осуществляющие уход, должны прикладывать все усилия к тому, чтобы наладить общение с подростком, даже если это непросто. Специальная информация для лиц, осуществляющих уход: X Постарайтесь найти приятные и интересные дела, которыми вы можете заниматься вместе. X Будьте последовательны относительно того, что вы разрешаете и не разрешаете делать подростку. X Хвалите или награждайте подростка за хорошее поведение и делайте замечания или предпринимайте соответствующие действия только в случае серьез- ных проблем с поведением. X Никогда не применяйте физическое наказание. Хвалите за хорошее поведение чаще, чем ругаете за плохое. X Не спорьте с подростком, когда вы очень расстроены. Подождите, пока вы не успокоитесь. Специальные вопросы для обсуждения с подростком: X Есть нормальные способы справиться со скукой, стрессом и злостью (например, занятия чем-то, что помогает расслабиться, занятия физической активно- стью, участие в общественной деятельности). XМожно поговорить с людьми, которым ты доверяешь, о том, что ты злишься, беспокоишься, что тебе бывает скучно или грустно. Это может помочь. X Алкоголь и другие вещества могут усугублять чувство злости и подавленности, и их не стоит употреблять. 60 П РО Ч » Поощряйте участие: в процессе формального/неформального образования; в конкретных, целенаправленных мероприятиях, представляющих общий интерес (например, создание приютов); в организованных спортивных программах. » Кроме этого, следуйте рекомендациям в разделе «Принци- пы снижения стресса и укрепления социальной поддержки» (см. «Общие принципы оказания помощи»), применимым к этой группе подростков и лицам, осуществляющим уход за ними. 4 . Последующее наблюдение » Порекомендуйте человеку повторно обратиться за помо- щью, если симптомы не исчезнут, усугубятся или станут непереносимыми. » При отсутствии улучшения, а также если человек или лицо, осуществляющее уход за ним, настаивают на дополнитель- ных исследованиях и лечении, обратитесь за советом к специалисту. 61 1 . Эпилепсия/припадки Наличие как минимум двух припадков в отсутствие явной причины (лихорадки, инфекции, травмы или синдрома отмены алкоголя). Эти припадки проявляются потерей сознания, дрожанием конечностей и иногда сопровожда- ются физическими повреждениями, недержанием кала или мочи и прикусыванием языка. 2 . Расстройство, связанное с употребле- нием алкоголя и других психоактив- ных веществ Человек с этим расстройством употребляет алкоголь и другие вещества, вызывающие привыкание, и не может адекватно контролировать их употребление. При этом ча- сто возникают проблемы в личных отношениях, ухудша- ется работоспособность и физическое состояние. Чело- век продолжает употреблять алкоголь и другие вещества, вызывающие привыкание, несмотря на эти проблемы. 3. Умственная отсталость Человек имеет очень низкий уровень умственного раз- вития, что является причиной проблем в повседневной жизни. Дети медленно учатся говорить. Взрослые могут выполнять только простые задания. Такие люди редко могут жить без посторонней помощи и самостоятельно обслуживать себя и (или) людей, находящихся у них на иждивении. При тяжелой степени инвалидности могут отмечаться нарушения речи и трудности в понимании других людей; человек может нуждаться в постоянной помощи. 4. Психотическое расстройство (в том числе мания) Люди могут слышать или видеть то, чего в действитель- ности нет, или иметь стойкие ложные убеждения. Они могут разговаривать сами с собой и странно выглядеть, их речь может быть спутанной или непоследовательной. Они могут не следить за собой. В другое время могут на- блюдаться периоды чрезмерной радости, раздражения, прилива сил, разговорчивости и беспокойства. Другие люди из такой же культурной среды считают этих людей «сумасшедшими» или крайне странными. К этой катего- рии относятся острый психоз, хронический психоз, мания и делирий. 5. Эмоциональное расстройство / де- прессия средней и тяжелой степени У этих людей отмечается значительное нарушение нормальной повседневной жизни в течение более двух недель вследствие а) глубокой печали/апатии и (или) б) чрезмерной неконтролируемой тревоги/страха. Часто возникают проблемы в личных отношениях, нарушения аппетита, сна и концентрации внимания. Люди могут жаловаться на сильное чувство усталости, могут на- ходиться в изоляции от общества, часто проводить в постели значительную часть дня. У них часто возникают суицидальные мысли. К этой категории относятся инвалидизирующие формы депрессии, тревожных расстройств и посттравматиче- ского стрессового расстройства (характеризующегося по- вторным переживанием прошлых событий, стремлением избегать всего, что напоминает о пережитом, и пере- возбуждением). Более легкие формы этих расстройств относятся к категории «другие психологические жалобы». 6. Другие психологические жалобы К этой категории относятся жалобы, связанные с эмо- циями (например, подавленное настроение, тревога) мыслями (например, повторение одних и тех же мыслей, низкая концентрация внимания) и поведением (напри- мер, пассивность, агрессия, избегание каких-то факторов или ситуаций). В большинстве обычных повседневных ситуаций у таких людей не возникает проблем. Жалобы могут быть симпто- мом менее тяжелого эмоционального расстройства (на- пример, легких форм депрессии, тревожного расстрой- ства или посттравматического стрессового расстройства) или проявлением обычной стрессовой реакции (т. е. без развития патологии). Критерии включения: к этой категории относятся только те люди, которые а) обратились за помощью в связи с на- личием указанных жалоб и б) не соответствуют критери- ям ни одной из пяти предыдущих категорий. 7. Соматические жалобы, не объясни- мые физическим состоянием К этой категории относятся любые соматические жалобы/ жалобы на физическое состояние при отсутствии явной органической патологии, которая могла бы объяснить их наличие. Критерии включения: человека можно относить к этой категории только после проведения всех необходимых исследований физического состояния. К ней относятся только те люди, которые а) не соответствуют критериям ни одной из шести предыдущих категорий и б) обрати- лись за помощью в связи с наличием указанных жалоб. 62 10 В тексте документа термины из словаря отмечены звездочкой (*). 11 Рабочие определения, приведенные в словаре, предназначены для использования только в рамках документа «Руководство по гуманитарной помощи mhGAP (mhGAP-HIG): лечение психических и неврологических расстройств и расстройств, связанных с употреблением наркотиков и других веществ, в гуманитарных чрезвычайных ситуациях» (ВОЗ и УВКБ ООН, 2015 г.). Асцит Патологическое скопление жидкости в брюшной полости вследствие разных причин. Акатизия Субъективное ощущение беспокойства, часто сопровождаемое видимыми чрезмерными движения- ми (например, суетливыми движениями ногами, переминанием с ноги на ногу, ходьбой из стороны в сторону, неспособностью спокойно сидеть или стоять). Амфетамины Группа лекарственных средств, оказывающих стимулирующее воздействие на центральную нервную систему. Эти средства могут улучшать психомоторные реакции и усиливать ощущение бодрствования. Они могут составлять основу терапии некоторых заболеваний, но также являются наркотическими средствами, вызывающими зависимость, и могут вызывать галлюцинации, депрес- сию и изменения со стороны сердечно-сосудистой системы. Поведенческая активация Форма психотерапии, целью которой является улучшение настроения человека путем повторного привлечения его, несмотря на подавленное состояние в данный момент, к целенаправленным за- нятиям, которые раньше доставляли удовольствие. Может применяться как отдельный вид лечения или как элемент когнитивной поведенческой терапии. Бензодиазепины Группа лекарственных средств, обладающих седативным (снотворным), анксиолитическим (умень-шение тревоги), противосудорожным и миорелаксирующим эффектами. Биполярное расстройство Тяжелое психическое расстройство, характеризующееся чередованием маниакальных и депрессив- ных эпизодов. Угнетение костного мозга Подавление функции костного мозга, которое может приводить к нарушению образования клеток крови. Конопля Общее название частей растения конопля, из которого получают марихуану, гашиш и гашишное масло. Эти вещества курят либо употребляют внутрь для того, чтобы вызвать эйфорию, рассла- бление и изменить процесс восприятия. Они могут иметь болеутоляющий эффект. Отрицательные эффекты включают развитие демотивации, тревожного возбуждения и паранойи. Церебральный паралич Расстройство, сопровождающееся двигательными нарушениями и нарушениями интеллекта вслед- ствие стойкого поражения головного мозга на ранних стадиях развития. Когнитивный Психические процессы, связанные с мышлением. К ним относятся обоснование, запоминание, суждение, решение проблем и планирование. Когнитивно- поведенческая терапия (КПТ) Форма психотерапии, сочетающая когнитивную и поведенческую терапию. Цель когнитивной тера- пии – изменить мышление человека, например, путем выявления необоснованных отрицательных мыслей и воздействия на них. Поведенческая терапия направлена на изменение формы поведения, например, путем побуждения человека заниматься более стоящими делами. Когнитивно- поведенческая терапия с акцентом на травмирующем переживании (КПТ-Т) Форма психотерапии, основанная на идее о том, что у людей, переживших травмирующее событие, присутствуют бесплодные мысли и убеждения, связанные с этим событием и его последствиями. Вследствие этих мыслей и убеждений человек начинает избегать всего, что напоминает о пере- житом событии, однако это не дает нужного результата; при этом у человека также появляется ощущение нависшей угрозы. Терапия обычно заключается в обеспечении воздействия факторов, напоминающих о травмирующем событии, и воздействии на связанные с ним бесплодные мысли и убеждения. Реабилитация на уровне местного сообщества Ряд мер, реализуемых посредством многокомпонентной стратегии на уровне местного сообщества с помощью имеющихся местных ресурсов и учреждений. Эти меры направлены на обеспечение реабилитации инвалидов за счет повышения качества их жизни и жизни членов их семей, обеспече- ния их основных потребностей, включения в жизнь общества и участия в ней. Делирий Преходящее психическое состояние, характеризующееся нарушением внимания (т. е. ухудшением способности направлять, концентрировать, удерживать и переключать внимание) и ориентировки в месте и времени, которое сохраняется в течение небольшого промежутка времени и изменяется в течение дня. Оно сопровождается (другими) нарушениями восприятия, памяти, мышления, эмо- ционального состояния или колебаниями психомоторных проявлений. Это состояние может быть вызвано острой органической патологией, например инфекцией, применением лекарственных средств, нарушениями обмена веществ, интоксикацией психоактивными веществами или синдро- мом отмены таких веществ. 63 Бред Стойкое убеждение, противоречащее имеющимся фактам. Его нельзя изменить с помощью рацио- нальной аргументации, и оно не входит в круг убеждений людей той же культуры или субкультуры (т. е. не является элементом религиозной веры). Зависимость Зависимостью от какого-либо вещества (наркотика, алкоголя и табака) считается состояние, при котором в отсутствии этого вещества у человека развиваются когнитивные, поведенческие и физиологические изменения, вызывающие чувство дискомфорта. Такие проявления синдрома отмены побуждают человека принимать это вещество еще в большем количестве. Человек не может контролировать употребление этого вещества и продолжает его употреблять, несмотря на неблаго- приятные последствия. Расширенные/ суженные зрачки Зрачок (черная часть глаза) – отверстие в центре радужки, которое регулирует количество све- та, поступающего в глаз. В нормальном состоянии зрачки сужаются (уменьшаются) на свету, что обеспечивает защиту структур в задней части глаза, и расширяются (увеличиваются) в темноте, что обеспечивает поступление в глаз максимального количества света. Расширение и сужение зрачков может быть признаком нахождения под воздействием лекарственных средств или наркотиков. Синдром Дауна Генетическое заболевание, обусловленное наличием дополнительной 21-й хромосомы. Оно прояв- ляется умственной отсталостью разной степени, задержкой физического развития и характерными чертами лица. Влияние лекар- ственного средства на сопутствующее заболевание Ситуация, при которой лекарственное средство, назначенное для лечения одного заболевания, влияет на другое заболевание у того же человека. Лекарственное взаимодействие Ситуация, при которой два лекарственных средства вступают во взаимодействие в организме человека, что приводит к изменению эффекта (эффектов) одного или обоих из них. Такое взаимо- действие может приводить к ослаблению, усилению или ускорению развития эффекта (эффектов) одного из лекарственных средств или к развитию токсического эффекта (эффектов). Экстрапирамид- ные побочные эффекты Нарушения двигательной активности мышц, чаще всего вследствие применения нейролептиков. К ним относятся тремор, скованность и спазм мышц и (или) акатизия. Десенсибилизация и переработка движениями глаз (ДПДГ) Форма психотерапии, основанная на идее о том, что неприятные мысли, чувства и нарушения поведения возникают из-за того, что воспоминания о травмирующем событии не были перерабо- таны. Лечение включает проведение стандартизированных процедур, во время которых пациент одновременно концентрируется на а) ассоциациях с травмирующими представлениями, мыслями, эмоциями и физическими ощущениями и б) билатеральной стимуляции, которая чаще всего пред- ставляет собой повторяющиеся движения глаз. Яркое повторное переживание Эпизод, во время которого человек думает и действует так, как будто он находится в момент совер- шения какого-то события из прошлого и снова переживает его. Во время ярких повторных пережи- ваний люди на короткое время (обычно на несколько секунд или минут) теряют связь с действитель- ностью. Галлюцинации Ложное восприятие действительности: люди видят, слышат и ощущают то, чего нет на самом деле, чувствуют несуществующие запахи и вкусы. Печеночная энцефалопатия Патологическое психическое состояние, обусловленное нарушением функции печени и проявляю- щееся сонливостью, спутанностью сознания и комой. Гипертиреоз Состояние, при котором в щитовидной железе вырабатывается и секретируется избыточное коли- чество гормонов. Некоторые симптомы этого нарушения, например делирий, тремор, повышение артериального давления и частоты сердечных сокращений, можно принять за проявления синдро- ма отмены алкоголя. Гипервентиляция Патологически учащенное дыхание, приводящее к гипокапнии (снижение содержания CO2 в крови). Это может сопровождаться появлением характерных симптомов, таких как покалывание или ощу- щение пощипывания в пальцах рук и вокруг рта, боль в грудной клетке и головокружение. Гипогликемия Патологически низкое содержание глюкозы (сахара) в крови. Гипонатриемия Патологически низкое содержание натрия (соли) в крови. Гипотиреоз Патологически низкая активность щитовидной железы. У взрослых это может приводить к появ- лению ряда симптомов, в том числе утомляемости, летаргии, увеличению массы тела и подавлен- ности, которую можно ошибочно принять за депрессию. При наличии на момент рождения это нарушение может приводить к умственной отсталости и задержке роста при отсутствии лечения. Межличностная психотерапия (МЛПТ) Форма психотерапии, при которой основное внимание направлено на связь между симптомами де- прессии и проблемами межличностного взаимодействия, особенно в случаях утраты, конфликтов, изоляции и серьезных жизненных перемен. 64 Навязчивые воспо- минания Повторяющиеся нежелательные, неприятные воспоминания о травмирующем событии. Дефицит йода Состояние, при котором содержание йода в организме недостаточно для нормального образования гормонов щитовидной железы, что приводит к нарушению роста и развития. Кат Листья кустарникового растения Catha edulis, в которых содержится стимулирующее вещество. Это вещество может употребляться как рекреационный наркотик (только для развлечения), но может вызывать и наркотическую зависимость. Методика «перека- тывания бревна» Методика переворачивания человека с одного бока на другой, не сгибая шею и спину, что позволя- ет предотвратить повреждение спинного мозга. Паралич, не объ- яснимый физиче- ским состоянием Частичная или полная утрата силы в любой части тела при невозможности выявить органическую патологию, которая могла бы быть причиной эти изменений. Раздражение моз- говых оболочек Раздражение слоев ткани, покрывающих головной и спинной мозг, обычно обусловленное инфек- цией. Нарушение обмена веществ Нарушение, затрагивающее гормоны, минералы, электролиты или витамины. Скорбь Действия, производимые как в частной, так и в общественной жизни, посредством которых чело- век, понесший утрату, отдает дань умершему, прощается с ним и увековечивает его память. Скорбь часто проявляется во время ритуалов, например похорон, и при соблюдении традиционных правил поведения, таких как ношение другой одежды, отказ от выхода в общество и соблюдение поста. Нейроинфекция Инфекция, поражающая головной и (или) спинной мозг. Злокачественный нейролептический синдром Редкое угрожающее жизни состояние, вызываемое применением нейролептиков, которое проявля- ется лихорадкой, делирием, мышечной ригидностью и повышением артериального давления. Нестероидные противовоспали- тельные средства (НПВС) Группа лекарственных средств, используемых для подавления воспаления. Они часто используются для облегчения боли (например, ибупрофен – представитель группы НПВС). Опиаты Наркотические вещества, получаемые из опийного мака. Опиаты – очень эффективные болеутоляю-щие средства, но могут вызывать пристрастие и зависимость. Героин относится к группе опиатов. Ортостатическая гипотензия Внезапное снижение артериального давления, которое может происходить при переходе из поло- жения лежа в положение сидя или стоя и обычно сопровождается появлением головокружения или ощущения дурноты. Это состояние не угрожает жизни. Полипрагмазия Одновременное назначение нескольких лекарственных средств для лечения одного заболевания. Потенциально травмирующее событие Любое устрашающее или пугающее событие, например физическое или сексуальное насилие, присутствие при актах жестокости, разрушение собственного жилища, крупные аварии или травмы. Будет ли такое событие восприниматься как травмирующее, зависит от эмоциональной реакции человека. Консультирова- ние по решению проблем Форма психотерапии, заключающаяся в систематическом выявлении проблем и использовании методик для их решения на протяжении нескольких занятий. Методики решения проблем Методики совместной работы с пациентами, направленной на использование метода «мозгового штурма» для поиска решений выявленных проблем, способов справиться с ними, распределение их по степени важности и обсуждение способов реализации этих решений и применения стратегий. В программе mhGAP термин «консультирование по решению проблем» применяется для описания систематического использования этих методик на протяжении нескольких занятий. Псевдоприпадок Эпизод, который по внешним проявлениям похож на эпилептический припадок, но не является таковым. Такие эпизоды по некоторым признакам (потеря сознания и особенности движения) могут очень напоминать эпилептические припадки, однако прикусывание языка, выраженные синяки вследствие падений и недержание мочи наблюдаются редко. При таких эпизодах в электрической активности мозга нет изменений, характерных для эпилептических припадков. Наблюдающиеся симптомы не обусловлены неврологическим расстройством или непосредственным воздействием психоактивных веществ или лекарственных средств. В МКБ-11 предлагается относить эти эпизоды к категории диссоциативного двигательного расстройства. 65 Первая психоло- гическая помощь (ППП) Предоставление поддержки и помощи людям в стрессовом состоянии, которые недавно столкну- лись с критической ситуацией. Это включает оценку неотложных потребностей и обеспокоенно- сти, обеспечение удовлетворения основных неотложных физических потребностей, обеспечение социальной поддержки или мобилизацию соответствующих ресурсов и обеспечение защиты от причинения вреда в будущем. Утрата приобре- тенных навыков Поведение ребенка, не соответствующее его возрасту, но нормальное для детей более младшего возраста. Частые проявления – ночное недержание мочи и повышенная эмоциональная зависи- мость у детей более старшего возраста. Угнетение дыхания Патологическое снижение частоты дыхания, приводящее к нехватке кислорода. Частые причины – травма головного мозга и интоксикация (например, вследствие применения бензодиазепинов). Припадок Эпизод нарушения функции головного мозга вследствие появления патологических электрических разрядов. Самоповреждение Намеренное употребление яда или нанесение себе повреждений, независимо от того, привело ли это к смерти и было ли у человека намерение покончить с жизнью. Самолечение Самостоятельное решение о необходимости употребления алкоголя или наркотических средств (в том числе рецептурных препаратов) для облегчения физических страданий и психологических проблем без консультации со специалистом. Сепсис Угрожающее жизни состояние, вызванное тяжелой инфекцией, проявляющееся лихорадкой, нару-шением кровообращения и работы органов. Шок Состояние, при котором наблюдается острая недостаточность кровообращения в результате инфекции или воздействия на организм других токсинов, что может привести к падению артери- ального давления до уровня, при котором невозможно обеспечение жизнедеятельности. Проявле- ния шока – низкое или неопределяемое артериальное давление, похолодание кожных покровов, слабый пульс или отсутствие пульса, затрудненное дыхание и нарушение сознания. СИОЗС Селективные ингибиторы обратного захвата серотонина: группа антидепрессантов, которые изби- рательно блокируют обратный захват серотонина. Серотонин – химическое вещество-посредник (нейромедиатор) в головном мозге, которое предположительно влияет на настроение человека. Флуоксетин – представитель группы СИОЗС. Стероиды Группа гормонов, выполняющих важные функции, в том числе подавление воспалительных реакций при инфекции, интоксикации и других иммунных нарушениях. Эти гормоны выпускаются в виде лекарственных препаратов. Примеры лекарственных препаратов стероидных гормонов: глюкокор- тикоиды (например, преднизолон) и гормональные контрацептивы. Синдром Стивен- са – Джонсона Угрожающее жизни поражение кожи, проявляющееся болезненным шелушением, образованием язв, пузырей и корок на слизистых оболочках и коже (слизистой оболочке ротовой полости, губ, горла, языка, глаз и половых органах) и иногда лихорадкой. Наиболее частая причина – тяжелая реакция на лекарственные вещества, особенно на противоэпилептические препараты. Суицид Умышленное лишение себя жизни. ТЦА Трициклические антидепрессанты: группа антидепрессантов, блокирующих обратный захват нейро- медиаторов норадреналина и серотонина. Амитриптилин и кломипрамин – представители группы ТЦА. Привыкание Ослабление эффекта препарата при применении в той же дозе. Это объясняется привыканием орга- низма к препарату при его многократном применении. В такой ситуации для достижения аналогич- ного эффекта требуются более высокие дозы. Токсический эпидермальный некролиз Угрожающее жизни поражение кожи, проявляющееся шелушением; обычно развивается вслед- ствие реакции организма на лекарственное средство или инфекцию. Это состояние похоже на синдром Стивенса – Джонсона, но протекает в более тяжелой форме. Трамадол Рецептурный препарат из группы опиоидов, использующийся для облегчения боли. Иногда исполь- зуется не по назначению, так как способен вызвать чувство эйфории (ощущение «подъема» или счастья). Тремор Дрожащие или колебательные движения, обычно пальцев рук. Уросепсис Сепсис, вызванный инфекцией мочевых путей. 66 Тревожность Острое стрессовое расстройство (ОСР) Депрессивное расстройство средней или тяжелой степени (ДЕП) Посттравматическое стрессовое расстройство (ПТСР) Психоз (ПСИ) Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Нарушение аппетита Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Ночное недержание мочи Острое стрессовое расстройство (ОСР)Умственная отсталость (УО) Спутанность сознания Психоз (ПСИ) Эпилепсия/припадки (ЭПИ) Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Бред Психоз (ПСИ) Трудности в выполнении обычных дел Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Посттравматическое стрессовое расстройство (ПТСР) Психоз (ПСИ) Умственная отсталость (УО) Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Яркие повторные переживания Острое стрессовое расстройство (ОСР)Посттравматическое стрессовое расстройство (ПТСР) Галлюцинации Психоз (ПСИ)Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Ощущение беспомощности Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Суицид (СУИ) Гипервентиляция Острое стрессовое расстройство (ОСР) Недержание мочи Эпилепсия/припадки (ЭПИ)Умственная отсталость (УО) Бессонница Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Посттравматическое стрессовое расстройство (ПТСР) Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Навязчивые воспоминания Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Посттравматическое стрессовое расстройство (ПТСР) Раздражительность Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Посттравматическое стрессовое расстройство (ПТСР) Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Трудности в обучении Умственная отсталость (УО) Упадок сил Горе (ГОРЕ)Депрессивное расстройство средней или тяжелой степени (ДЕП) 67 Снижение интереса и способности получать удовольствие Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Несоблюдение гигиены Психоз (ПСИ) Умственная отсталость (УО) Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Нарушение концентрации внимания Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Посттравматическое стрессовое расстройство (ПТСР) Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Подавленное настроение Горе (ГОРЕ)Депрессивное расстройство средней или тяжелой степени (ДЕП) Припадки, судороги Эпилепсия/припадки (ЭПИ)Пагубное употребление алкоголя и наркотических средств (ВЕЩ) Самоповреждение Суицид (СУИ) Социальная самоизоляция Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Психоз (ПСИ) Необъяснимые соматические симпто- мы Острое стрессовое расстройство (ОСР) Горе (ГОРЕ) Депрессивное расстройство средней или тяжелой степени (ДЕП) Посттравматическое стрессовое расстройство (ПТСР) Программа действий ВОЗ по ликвидации пробелов в области охраны психического здоровья В чрезвычайных гуманитарных ситуациях в каждом неспециализированном медицинском учреждении как минимум один медицинский работник, работающий под руководством другого сотрудника, должен уметь проводить оценку психических и неврологических расстройств, а также расстройств, связанных с употреблением наркотиков и других веществ, и принимать соответствующие меры . «Руководство по гуманитарной помощи mhGAP (mhGAP-HIG)» – простое практическое пособие, предназначенное для оказания помощи в достижении этой цели . ISBN 978 92 4 454892 9

المعالجة السريرية للاضطرابات النفسية والعصبية واستخدام مواد الإدمان في حالات الطوارئ الإنسانية دليل التدخلات الإنسانية لبرنامج رأب الفجوة في الصّحة النفسية (GIH-PAGhm) برنامج رأب الفجوة في الصّحة النفسية قام بمراجعة النسخة العربية لبنان د. ميشال صوفيا – الهيئة الطبية الدولية د. ربيع الشماعي – وزارة الصحة العامة د. لينا صادق – وزارة الصحة العامة د. وسام خير – وزارة الصحة العامة ادوينا زغبي – منظمة الصحة العالمية الاردن مرام شاهين – الهيئة الطبية الدولية د. علاء الدين المصري – الهيئة الطبية الدولية د. راما عبيلي – الهيئة الطبية الدولية د. رامي سميح – الهيئة الطبية الدولية ديما الفرح – الهيئة الطبية الدولية تركيا د. بسمه عبد الرحمن – الهيئة الطبية الدولية د. محمود حجازي – الهيئة الطبية الدولية د. ناصر حافظ – الهيئة الطبية الدولية د. نضال سعدون – الهيئة الطبية الدولية محمد عجوم – الهيئة الطبية الدولية سويسرا د. فهمي بهجت حنا – منظمة الصحة العالمية WHO Library Cataloguing-in-Publication Data mhGAP Humanitarian Intervention Guide (mhGAP-HIG): clinical management of mental, neurological and substance use conditions in humanitarian emergencies. 1. Mental Disorders. 2. Substance-related Disorders. 3. Nervous System Diseases. 4. Relief Work. 5. Emergencies. I. World Health Organization. II. UNHCR. ISBN 978 92 4 654892 7 (NLM classification: WM 30) © منظمة الصّحة العالمية، 6102 جميع الحقوق محفوظة. يمكن الحصول على مطبوعات منظمة الصحة العالمية من على موقع المنظمة الإلكتروني )tni.ohw.www( أو شراءها من قسم الطباعة والنشر، منظمة الصحة العالمية 02 dnalreztiwS، 72 aveneG 1121، aippA eunevA )هاتف رقم: ؛ فاكس رقم: ؛ عنوان البريد الإلكتروني: tni.ohw@sredrokoob(. وينبغي توجيه طلبات الحصول على الإذن باستنساخ أو ترجمة منشورات منظمة الصحة العالمية - سواء كان ذلك لبيعها أو لتوزيعها توزيعا ًغير تجاري - إلى قسم الطباعة والنشر عبر موقع المنظمة الإلكتروني )lmth.xedni/ne/mrof_thgirypoc/gnisnecil/tuoba/tni.ohw.www( والتسميات المستخدمة في هذا المطبوع، وطريقة عرض المواد الواردة فيه، لا تعبر إطلاقا ًعن رأي منظمة الصحة العالمية بشأن الوضع القانوني لأي بلد، أو إقليم، أو مدينة، أو منطقة، أو لسلطات أي منها، أو بشأن تحديد حدودها أو تخومها. وتشكل الخطوط المنقوطة على الخرائط خطوطا ً حدودية تقريبية قد لا يوجد بعد اتفاق كامل عليها. وذكر شركات بعينها أو منتجات جهات صانعة معينة لا يعني أن هذه الشركات والمنتجات معتمدة، أو موصى بها من قبل منظمة الصحة العالمية، تفضيلاً لها على سواها مما يماثلها ولم يرد ذكره. وفيما عدا الخطأ والسهو، تميز أسماء المنتجات المسجلة الملكية بوضع خط تحتها. وقد اتخذت منظمة الصحة العالمية كل الاحتياطات المعقولة للتحقق من صحة المعلومات الواردة في هذا المطبوع. ومع ذلك فإّن المواد المنشورة توزع دون أي ضمان من أي نوع صريحا ًكان أو ضمنيا.ً والقارئ هو المسؤول عن تفسير واستعمال المواد المنشورة. والمنظمة ليست مسؤولة بأي حال عن الأضرار التي تترتب على استعمال هذه المواد. طبع من قبل قسم خدمات إعداد وثائق منظمة الصحة العالمية، جنيف، سويسرا 4623 197 22 14+ 7584 197 22 14+ تمهيد يواجه العالم اليوم عددا ًلا سابق له من حالات الطوارئ الإنسانية الناشئة عن النزاعات المسلحة والكوارث الطبيعية. إن عدد اللاجئين والأشخاص النازحين داخليا ًلم يبلغ هذا الحد المرتفع منذ انتهاء الحرب العالمية الثانية، فعشرات الملايين من الأشخاص ولاسيّما في الشرق الأوسط وافريقيا وآسيا هم بحاجة ماسة للمساعدة، وذلك يشمل الخدمات القادرة على تلبية الحاجات المتصاعدة للسكان في مجال الصّحة النفسية. إن الأطفال والبالغين المتأثرين بحالات الطوارئ يعانون من مجموعة متنّوعة وجوهرية من المشاكل النفسية والعصبية واستخدام مواد الإدمان. في المحن الشديدة، يُصاب معظم الأشخاص بالحزن والضيق الشديد كردود فعل نفسيّة طبيعية مؤقتة. أما بالنسبة إلى أقلية من السكان فالمحن الشديدة تسبّب لهم مشاكل نفسية كالاضطراب الاكتئابي أو اضطراب الكرب ما بعد الصدمة أو اضطراب الحزن الطويل الأمد، وهي جميعها اضطرابات من شأنها أن تقّوض بشدة الأداء الوظيفي اليومي للأشخاص. فضلاً عن أن الأشخاص الذين يعانون في الأصل من الاضطرابات الحادة كالذهان والإعاقة الذهنية والصرع يصبحون أكثر تأثرا،ً ربما بفعل النزوح والهجر وعدم الحصول على الخدمات الصحية. وأخيرا،ً إن تعاطي الكحول ومواد الإدمان يشكل خطرا ًحقيقيا ًفي ما يتّصل بالمشاكل الصحية والعنف المبني على أساس النوع الاجتماعي. في الوقت الذي تتعاظم فيه حاجات الصّحة النفسية للسكان بدرجة كبيرة، غالبا ما تشّح موارد الرعاية الصحية النفسية. وفي مثل هذه الظروف، نحتاج أكثر من أي وقت مضى إلى الأدوات العملية السهلة الاستخدام. لقد تّم تطوير هذا الدليل بالاستناد إلى هذه التحّديات. إن دليل التدخلات الإنسانية لبرنامج رأب الفجوة في الصّحة النفسية هو بمثابة أداة عملية بسيطة تهدف إلى مساندة مرافق الصّحة العامة في المناطق المتأثرة بحالات الطوارئ الإنسانية في تقييم وتدبير الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. ولقد تّم إعداده إستنادا ًإلى دليل تدخلات برنامج رأب الفجوة في الصّحة النفسية لمنظمة الصّحة العالمية )0102(، وهو كتيب قائم على الأدلة، شائع الاستخدام، يرمي إلى معالجة هذه الاضطرابات في مواقع تقديم الرعاية الصحية غير التخّصصية، ولقد تّم تكييفه من أجل الاستخدام في حالات الطوارئ الإنسانية. يتوافق هذا الدليل تماما ًمع المبادئ التوجيهية للجنة الدائمة المشتركة بين الوكالات )CSAI( بشأن الصحة النفسية والدعم النفسي الاجتماعي في حالات الطوارئ ومع التوجيهات التنفيذية للمفوضية السامية للأمم المتحدة لشؤون اللاجئين بشأن الصّحة النفسية والدعم النفسي الاجتماعي في عمليات اللاجئين، وهي توجيهات تدعو إلى استجابة متعّددة القطاعات قادرة على مواجهة العواقب المترتّبة عن حالات الطوارئ الإنسانية والنزوح على مستوى الصّحة النفسية والمستوى الاجتماعي. كما يساعد هذا الدليل على تحقيق الهدف الرئيسي لخطة عمل منظمة الصّحة العالمية الشاملة الخاصة بالصّحة النفسية 3102-0202، لاسيّما توفير خدمات رعاية اجتماعية وصحية نفسية شاملة، متكاملة وسريعة الاستجابة ضمن البيئات المجتمعية. لذلك نناشد كافة الشركاء العاملين في المجال الإنساني ضمن القطاع الصحي اعتماد هذا الدليل الهام ونشره للمساعدة على تخفيف المعاناة وزيادة قدرة البالغين والأطفال ذوي الاحتياجات في مجال الرعاية الصحية النفسية على التصّدي في مواقع الطوارئ الإنسانية. مارغريت شان انطونيو غوترس المدير العام لمنظمة الصّحة العالمية لمفوض السامي للأمم المتحدة لشؤون اللاجئين i الفهرس شكر وتقدير .............................................................................................................................................................................................. VI مقدمة . ........................................................................................................................................................................................................ 1 النصح الموّجه لمدراء العيادات ....................................................................................................................................................................... ۳ المبادئ العامة لرعاية الأشخاص ذوي الاضطرابات النفسية والعصبية واستخدام مواد الإدمان في مواقع الطوارئ الإنسانية )CPG( .............................................................................................................................................................. 5 1. مبادئ التواصل .................................................................................................................................................................................... 5 ۲. مبادئ التقييم ...................................................................................................................................................................................... 7 ۳. مبادئ التدبير ....................................................................................................................................................................................... 8 ٤. مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي ......................................................................................................................... 9 5. مبادئ حماية حقوق الانسان ............................................................................................................................................................. 11 6. مبادئ التنبّه للرفاه العام ................................................................................................................................................................... 31 الوحدات 1. الكرب الحاد )UCA( ........................................................................................................................................................................ ٤1 ۲. الحزن )IRG( ................................................................................................................................................................................... 81 ۳. الاضطراب الاكتئابي المعتدل إلى الحاد )PED( ..................................................................................................................................... 22 ٤. اضطراب الكرب ما بعد الصدمة )DSTP( .......................................................................................................................................... 92 5. الذهان )YSP( ................................................................................................................................................................................. 23 6. الصرع / النوبات )IPE( .................................................................................................................................................................... 73 7. الإعاقة الذهنية)DI( ......................................................................................................................................................................... 3٤ 8. التعاطي الضار للكحول ومواد الإدمان )BUS( .................................................................................................................................... 7٤ 9. الانتحار )IUS( ................................................................................................................................................................................. 25 01. شكاوى الصحة النفسية الهامة الأخرى )HTO( ................................................................................................................................ 55 الملاحق الملحق 1: تعريف الحالات لنظام المعلومات الصحية )SIH( للمفوضية السامية للأمم المتحدة لشؤون اللاجئين )٤102( ............................. 85 الملحق ۲: قائمة المصطلحات ................................................................................................................................................................... 95 الملحق ۳: قائمة الأعراض ........................................................................................................................................................................ ٤6 iii شكر وتقدير التصّور مارك فان اومرين )منظمة الصحة العالمية(، يوتارو سيتويا )منظمة الصحة العالمية(، بيتر فنتفوغل )المفوضية السامية للأمم المتحدة لشؤون اللاجئين( وخالد سعيد )منظمة الصحة العالمية(، تحت إشراف شيخار ساكسينا )منظمة الصحة العالمية( وماريان شيلبرورد )المفوضية السامية للأمم المتحدة لشؤون اللاجئين(. صياغة المشروع وفريق التحرير بيتر فنتفوغل )المفوضية السامية للأمم المتحدة لشؤون اللاجئين(، كا يونغ بارك )مدرسة كندي في جامعة هارفرد( ومارك فان اومرين )منظمة الصحة العالمية(. فريق مراجعة برنامج رأب الفجوة في الصّحة النفسية لمنظمة الصّحة العالمية نيكولاس كلارك، ناتالي درو، تارون دويا، الكسندرا فلشمان، شيخار ساكسينا، شيارا سرفللي، يوتارو سيتويا، مارك فان اومرين، الكسندرا رايت وتاغي ياسامي. المساهمون الآخرون/المراجعون هلال اودين احمد )المعهد الوطني للصحة العقلية، بنغلادش(، كورادو باربوي )مركز تعاون منظمة الصحة العالمية للبحوث والتدريب في الصحة النفسية، جامعة فيرونا(، توماس باريت )جامعة دنفر(، بيار باستن )اللجنة الدولية للصليب الأحمر(، ميرون بلفر )كلية الطب في جامعة هارفرد(، مارغريت بلاو )المجموعة المرجعية للجنة الدائمة المشتركة بين الوكالات المعنية بالصحة النفسية والدعم النفسي الاجتماعي في حالات الطوارئ(، بوريس بودوسان )منظمة مالتيزر الدولية(، كنيث كارسول )منظمة الصحة العالمية(، جورج كاستيلا )مكتب المفوضية الاوروبية للمساعدات الإنسانية والحماية المدنية(، فانيسا كافاليرا )منظمة الصحة العالمية(، اليزابيث سنتينو-تابلانت )منظمة الصحة العالمية(، لوكاس شيني )جامعة ملبورن(، راشيل كوهن )sdaerTh nommoC(، أنا كوادرا )منظمة أطباء العالم(، كاتي داوسون )جامعة نيو ثاوث ويلز(، جوب دي جونغ )جامعة امستردام(، باميلا ديكس )noitcA retsasiD(، فريدريك دروغول )منظمة أطباء بلا حدود(، كارولينا اشيفري )المفوضية السامية للأمم المتحدة لشؤون اللاجئين(، ربيع الشماع )وزارة الصحة العامة، لبنان(، محمد الشاذلي )الهيئة الطبية الدولية(، مايكل فرست )جامعة كولومبيا(، ريتشارد غارفيلد )مراكز مكافحة الأمراض والوقاية منها(، انا غولاز )جامعة جنيف(، ديفيد غولدبرغ )كلية كينجز لندن(، مارلين غودفرند )منظمة أطباء بلا حدود(، مارغريت غريغ )DNIM ، استراليا(، نورمان غوستافسون )بارسا افغانستان(، فهمي حنا )منظمة الصحة العالمية(، ماثيجز هوغستاد )yticapac detailffia-non ni، هولندا(، بيتر هيوغ )الكلية الملكية للأطباء النفسانيين، المملكة المتحدة(، تاكاشي ايزوتسو )البنك الدولي(، لين جونز )كلية الصحة العامة في جامعة هافرد(، ديفورا كستل )منظمة الصحة للبلدان الامريكية/منظمة الصحة العالمية(، لويزا خورتا )المفوضية السامية للأمم المتحدة لشؤون اللاجئين(، كاري كوغان )جامعة اوتاوا(، روس كورست )htlaehlatnem2ni ، هولندا(، مارك لابورتا )جامعة مكغيل(، جاك لو روي )detailffia-non ni yticapac ، بلجيكا(، باربرا لوبيز كاردوزو )مراكز مكافحة الأمراض والوقاية منها(، ايدو لوري )أطباء من أجل حقوق الانسان، اسرائيل(، اندرياس ماركر )جامعة زوريخ(، هيني ماكيلا )بعثة المساعدة الدولية، افغانستان(، ادلهيد مارشانغ )منظمة الصحة العالمية(، كارمن مارتيناز-فيسيانا )منظمة أطباء بلا حدود(، جيسي مبوامبو )جامعة موهيمبيلي للصحة والعلوم المتحالفة، تنزانيا(، فرناندا منا باريتو كروم )منظمة أطباء العالم(، اندرو موهانراج )MBC، ماليزيا(، اميليو اوفوغا )جامعة غولو، اوغندا(، سارا بائيس )منظمة الصحة العالمية(، هيزر بابوويتز )اليونيسف)، كسافيي بريرا )s’rolyaT sevitaitinI ytiuqE htlaeH dna enicideM fo loohcS ytisrevinU، ماليزيا(، بو بريز-سيلز )مستشفى لاباز، اسبانيا(، جيوفاني بنتالدي )منظمة أطباء بلا حدود(، بهافا بوديال )yticapac detailffia-non ni، اذربايجان(، رشا رحمن )منظمة الصحة العالمية(، اندو راوبليسون )منظمة الرؤية الدولية للعالم(، نيك روز )جامعة اوكسفرد(، سيسيل روسو )جامعة مكغيل(، خالد سعيد )منظمة الصحة العالمية(، بندتو ساراثينو )edadisrevinU aobsiL ed avoN، البرتغال(، اليسون شافر )منظمة الرؤية الدولية للعالم(، ناتالي سفري )منظمة أطباء بلا حدود(، ياسوكو شينزاكي )منظمة أطباء العالم(، برامود موهان شيانغوا )المنظمة الدولية للهجرة(، ديريك سيلوف )جامعة نورث ساوث ويلز(، ستيفاني سميث )شركاء في الصحة(، لسلي سنايدر )مؤسسة رضوح الحرب(، يوريكو سوزوكي )المعهد الوطني للصحة النفسية، اليابان(، ساجي توماس )اليونيسف(، انا ماريا تيجرينو (منظمة أطباء بلا حدود)، ويتز تول )جامعة جونز هوبكنز ومؤسسة بيتر الدرمان(، سنوب تشاكرجان )منظمة أطباء العالم(، بهارات فيزا )منظمة الصحة العالمية(، انكا ويسبكر )الهيئة الطبية الدولية(، نانا ويدمن )الاتحاد الدولي للصليب الاحمر والهلال الاحمر( ووليام يول )كلية كينجز لندن(. التمويل المفوضية السامية للأمم المتحدة لشؤون اللاجئين التصميم viالينا شرشي

مقدمة لقد تّم إعداد هذا الدليل استنادا ًإلى دليل تدخلات برنامج رأب الفجوة في الصّحة النفسية (GI-PAGhm) للاضطرابات النفسية والعصبية واستخدام مواد الإدمان في مواقع تقديم الرعاية الصحية غير التخصصية لمنظمة الصّحة العالمية من أجل استخدامه في حالات الطوارئ الإنسانية. لذا نطلق عليه اسم دليل التدخلات الإنسانية لبرنامج رأب الفجوة في الصّحة النفسية )GIH-PAGhm(. ما هو برنامج رأب الفجوة في الصّحة النفسية (PAGhm)؟ لماذا نلتمس ضرورة التعديل وفقا ًلظروف الطوارئ الإنسانية؟ إن برنامج رأب الفجوة في الصّحة النفسية هو برنامج لمنظمة الصّحة العالمية يسعى إلى سّد النقص في مجال رعاية الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان )SNM( . وكجزء من هذا البرنامج تّم إصدار دليل تدخلات برنامج رأب الفجوة في الصّحة النفسية )GI-PAGhm( عام 0102، وهو دليل سريري في مجال الاضطرابات النفسية والعصبية واستخدام مواد الإدمان يتوّجه إلى مقّدمي الرعاية الصحية العامة العاملين في مواقع الرعاية الصحية غير التخّصصية، لاسيّما في البلدان المنخفضة والمتوسطة الدخل. ويتوّجه أيضا ًإلى الأطباء العاّمين، والممرضين، والقابلات، والمسؤولين السريريين، فضلا عن الأطباء المتخّصصين في مجالات أخرى غير الطب النفسي أو طب الجهاز العصبي. بالإضافة إلى المشورة السريرية، يوفر برنامج رأب الفجوة في الصّحة النفسية مجموعة من الأدوات التي تهدف إلى دعم تنفيذ البرنامج وتساعد على تحليل الأوضاع، وتعديل الأنظمة السريرية وفقا ًللظروف المحلية، وتخطيط البرامج، والتدريب، والإشراف والمراقبة.1 خلال حالات الطوارئ الإنسانية الناتجة عن النزاعات المسلحة والكوارث الطبيعية والصناعية على حّد سواء، تنشأ مجموعة واسعة من مواقع الطوارئ الحادة والمزمنة، كما يحصل غالبا ًفي حالة النزوح الجماعي للسكان. وفي مثل هذه الظروف، إن حاجات السكان إلى الخدمات الأساسية تفوق الطاقات المحلية نظرا ًلإمكانية تّضرر النظام المحلي من جراء حالة الطوارئ. بالتالي فإن الموارد تتراوح وفقا ًلتوفّر المساعدات الإنسانية المحلية والوطنية والدولية ووفقا ًلحجم هذه المساعدات. تطرح الأزمات الإنسانية سلسلة من التحّديات وتتيح لمقّدمي الخدمات الصحية فرصا ًاستثنائية تتطلب إرادة سياسية وموارد متزايدة لتلبية خدمات الصّحة النفسية وتحسينها.۲ وتضّم التحديات ما يلي: » ضرورة ملّحة لتخصيص الموارد الشحيحة ومنحها الأولوية » الوقت المحدود لتدريب مقّدمي الرعاية الصحية » الوصول المحدود للأخصائيين )من أجل التدريب، الإشراف، الإرشاد، الإحالة أو الاستشارة( » الوصول المحدود للأدوية نظرا ًلاختلال سلسلة الإمداد العادية لقد تّم تطوير دليل التدخلات الإنسانية لبرنامج رأب الفجوة في الصّحة النفسية بهدف التصّد ي لهذه التحديات في مواقع الطوارئ الإنسانية. محتوى هذا الدليل يحتوي دليل التدخلات الإنسانية لبرنامج رأب الفجوة في الصّحة النفسية على توصيات بشأن علاج الخط الأول للاضطرابات النفسية والعصبية واستخدام مواد الإدمان، موّجهة لمقّدمي الرعاية الصحية من غير المتخّصصين في حالات الطوارئ الإنسانية حيث يكون الوصول إلى الأطباء المتخصّص ين والى الخيارات العلاجية محدودا.ً يستخلص هذا الدليل المعلومات الأساسية من الدليل الكامل لتدخلات برنامج أ رب الفجوة في الصّحة النفسية )GI-PAGhm( ويضيف عناصر أخرى ترتبط بشكل خاص بظروف الطوارئ الإنسانية. يغطي هذا الدليل ما يلي: » النصح الموّجه لمدراء العيادات؛ » المبادئ العامة للرعاية القابلة للتطبيق في مواقع الطوارئ الإنسانية، بما في ذلك: توفير الدعم المتعّدد القطاعات وفقا ًللمبادئ التوجيهية للجنة الدائمة المشتركة بين الوكالات بشأن الصحة النفسية والدعم النفسي الاجتماعي في حالات الطوارئ )CSAI، 7002( وللتوجيهات التنفيذية بشأن الصّحة النفسية والدعم النفسي الاجتماعي في عمليات اللاجئين )RCHNU، 3102(؛ وأدوات أخرى متعلقة بحالات الطوارىء؛ 1 للحصول على نسخة من هذه الأدوات، الرجاء المراسلة على البريد الالكتروني tni.ohw@ofni-paghm 1seicnegreme refta erac htlaeh latnem elbaniatsus :retteb kcab gnidliuB۲ مراجعة منظمة الصّحة العالمية )OHW(، . منظمة الصّحة العالمية، جنيف، 3102. 2 تعليمات بشأن تقليص الضغط النفسي. » وحدات موجزة تتعلق بتقييم وتدبير الحالات التالية: الكرب الحاد )UCA( الحزن )IRG( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( اضطراب الكرب ما بعد الصدمة )DSTP( الذهان )YSP( الصرع/النوبات )IPE( الإعاقة الذهنية )DI( التعاطي الضار للكحول ومواد الإدمان )BUS( الانتحار )IUS( شكاوى الصحة النفسية الهامة الأخرى )HTO( كما تشمل التغييرات الأخرى ما يلي: » لقد تمّت إعادة صياغة إرشادات الاضطراب السلوكي في شكل توجيهات تتعلق بالمشاكل السلوكية لدى المراهقين، نجدها في وحدة شكاوى الصّحة النفسية الهامة الاخرى )HTO(. » لقد تّم تقسيم الوحدة المتعلقة بتقييم وتدبير الحالات المرتبطة بشكل خاص بالضغط النفسي لدليل تدخلات برنامج رأب الفجوة في الصّحة النفسية )منظمة الصّحة العالمية، 3102( إلى ثلاث وحدات: الكرب الحاد )UCA(، الحزن )IRG( واضطراب الكرب ما بعد الصدمة )DSTP(. » لقد تمّت إضافة قائمة بالمصطلحات. إن التعابير المقترنة بعلامة )*( معرّفة في الملحق 2. يُعتبر هذا الدليل أصغر حجما ًمقارنة بدليل تدخلات برنامج رأب الفجوة في الصّحة النفسية )GI-PAGhm( فهو لا يشتمل على الإرشادات بشأن ما يلي: » التسّمم بالكحول ومواد الإدمان والاعتماد* )ecnedneped( )إلا أن هذا الدليل يغطي الانقطاع عن الكحول والتعاطي الضار للكحول ومواد الإدمان(؛ » اضطراب فرط الحركة ونقص الانتباه )إلا أن هذا الدليل يغطي المشاكل السلوكية لدى المراهقين ضمن وحدة شكاوى الصحة النفسية الهامة الأخرى(؛ » اضطرابات طيف التوّحد؛ » الخرف )إلا أن هذا الدليل يغطي دعم القائمين على العناية بالأشخاص المصابين بأي من الاضطرابات النفسية والعصبية واستخدام مواد الإدمان ضمن المبادئ العامة للرعاية(؛ » الخطر غير الوشيك بإيذاء الذات؛ » علاجات الخط الثاني لمعظم الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. التوجيهات بشأن المواضيع الآنفة الذكر لا تزال متوفرة في الدليل الكامل لتدخلات برنامج رأب الفجوة في الصّحة النفسية )GI-PAGhm( . 3النصح الموّجه لمدراء العيادات إن عملية دمج الاضطرابات النفسية والعصبية واستخدام مواد الإدمان )SNM( ضمن حاجات الرعاية الصحية العامة يجب أن يشرف عليها قائد )مثلاً مسؤول الصّحة العامة على مستوى المنطقة، المدير الطبي للوكالة، الخ( يتوّلى تصميم الرعاية وتنسيقها في عدد من المرافق الصحية بالاستناد إلى تحليل الأوضاع ذات الصلة )مراجعة مجموعة أدوات التقييم لمنظمة الصّحة العالمية والمفوضية السامية للأمم المتحدة لشؤون اللاجئين 2102(. لكل مرفق صحي مدير عيادة )رئيس المرفق الصحي( يتوّلى مسؤوليات محّددة. يتوجب على مدراء العيادات الاطلاع على النقاط التالية. البيئة » تخصيص حّيز خاص، ويفّضل غرفة منفصلة، لإجراء الاستشارات بشأن الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. إن لم تتوفر غرفة منفصلة، محاولة تقسيم الغرفة باستخدام الستائر أو غيرها من الوسائل وذلك بغية توفير درجة قصوى من الخصوصيّة. » التنبّه لعدم تمييز الغرفة بأي علامة وذلك لتفادي عدم سعي الأشخاص للحصول على خدمات الرعاية في مجال الاضطرابات النفسية والعصبية واستخدام مواد الإدمان خوفا من الوصمة الاجتماعية. نموذج الخدمة » الحرص على تواجد فرد مدرب واحد على الأقل من طاقم الموظفين في أي وقت في الخدمة من أجل الاضطرابات النفسية والعصبية واستخدام مواد الإدمان، أي أن يتوّلى شخص تقييم وتدبير حالة الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان. » كبديل، يجب العمل على إقامة "عيادة خاصة بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان" مرّة أو مرتين في الأسبوع داخل مرفق الصّحة العامة، خلال الأوقات التي تخّف فيها أعمال العيادة. وفي حال قدوم المرضى خارج ساعات عمل العيادة الخاصة بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان، يمكن الطلب منهم بلطف العودة في ساعات عمل العيادة. إن إقامة مثل هذه العيادات أمر مفيد في المرافق الصحية ذات حجم العمل الهام، لاسيّما لإجراء التقييم الأساسي الذي يستغرق عادة وقتا ًأطول من زيارات المتابعة. الهيكل الوظيفي والتدريب » إعلام كافة الموظفين بضرورة توفير بيئة داعمة للأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان. » تحديد الموظفين الواجب تدريبهم على توفير الرعاية في مجال الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. » التأكد من توفّر الموارد ليس للتدريب فحسب وإنما للإشراف أيضا.ً إن الإشراف السريري من جانب الموظفين يشكل جزءا ًأساسيا ًمن الرعاية الجيّدة في مجال الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. » إذا تّم تدريب عدد ضئيل من الموظفين فقط على محتوى هذا الدليل، يجب الحرص على أن يتمّكن الموظفون السريري ون الباقون من تقديم الإسعافات النفسية الأولية* )-dia tsrfi lacigolohcysp AFP( على الأقل. الإرشاد على الإسعافات النفسية الأولية يستغرق نصف نهار تقريبا.ً يمكن إيجاد دليل الإسعافات النفسية الأولية للعاملين الميدانيين والمواد التوجيهية المرافقة المخّصصة للميّسرين على الانترنت. » إرشاد موظف الاستقبال )أو الشخص القائم بمثل هذا الدور( حول كيفية التعامل مع أشخاص في حال هياج قد تستدعي حالتهم اهتماما ً فوريا.ً » تدريب العاملين المجتمعيين والمتطوعين، في حال تواجدهم، على كيفية )أ( رفع مستوى الوعي بشأن الرعاية في مجال الاضطرابات النفسية والعصبية واستخدام مواد الإدمان )راجع أدناه(، )ب( مساندة الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان في الحصول على المساعدة داخل العيادة و)ج( المساعدة على الرعاية في أثناء المتابعة. » النظر في تعيين فرد من فريق الرعاية الصحية )مثلاً ممرض، أخصائي نفسي اجتماعي، أخصائي اجتماعي محلي( ليتّم تدريبه على توفير الدعم النفسي الاجتماعي )كتوفير العلاج النفسي القصير، إدارة مجموعات المساعدة الذاتية، تعليم كيفية التعامل مع الضغط النفسي( والإشراف عليه. » إرشاد كافة الموظفين بشأن تدابير الحماية المحلية: شروط موافقة الشخص وحدودها، بما في ذلك التبليغ عن الحالات المشتبه بها من الإساءة إلى الأطفال، والعنف الجنسي والعنف المبني على أساس النوع الاجتماعي وغيرها من انتهاكات حقوق الإنسان، تحديد الأسر، تتبّع أثرها واعادة لمّ شملها. يجب بشكل خاص حماية الأطفال المنفصلين عن ذويهم واحالتهم إلى تدابير الرعاية المؤقتة الملائمة، عند الحاجة. » في حال تعيين اختصاصيين دوليين في الصّحة النفسية تابعين للعيادة بهدف الإشراف، يجب اطلاعهم باختصار على الثقافة والبيئة المحلية. » إرشاد كافة الموظفين حول كيفية الإحالة إلى الخدمات المتاحة. الإحالة » التأكد من أن تتوفّر داخل العيادة قائمة محّدثة بالأرقام من أجل الإحالة إلى خدمات الرعاية في مجال الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. » التأكد من أن تتوفّر داخل العيادة قائمة محّدثة بالأرقام العائدة لموارد الدعم الأخرى المتوفرة في المنطقة )كالحاجات الأساسية مثل المأوى والمساعدات الغذائية، الموارد والخدمات المجتمعية والاجتماعية، الحماية والدعم القانوني(. رفع مستوى الوعي حول الخدمات المتوفرة » إعداد رسائل مجتمعية تتعلق بالرعاية المتوفرة في مجال الاضطرابات النفسية والعصبية واستخدام مواد الإدمان )على سبيل المثال، هدف هذه الرعاية وأهميتها، الخدمات المتوفرة في العيادة، موقع العيادة وساعات العمل(. » مناقشة الرسائل مع قادة المجتمع. » استخدام قنوات نشر المعلومات المختلفة، كالراديو، الملصقات داخل العيادات، العاملين المجتمعيين أو الموارد المجتمعية الأخرى القادرة على إعلام مجمل السكان. » عند الحاجة، النظر في مناقشة الرسائل مع المعالجين التقليديين والشعبيين المحليين فلعلّهم يقدمون العلاج لأشخاص مصابين باضطرابات نفسية وعصبية واستخدام مواد إدمان ويرغبون في التعاون واحالة بعض الحالات )لمزيد من التوجيهات، مراجعة ورقة العمل 6.٤ للمبادئ التوجيهية للجنة الدائمة المشتركة بين الوكالات بشأن الصحة النفسية والدعم النفسي الاجتماعي في حالات الطوارئ CSAI، 7002(] » بلوغ المجموعات المهّمشة التي يمكن أن تكون غير منتبهة للعيادة أو عاجزة عن الوصول إليها. الأدوية » العمل مع صانعي القرار المعنيين لضمان إمداد مستمر بالأدوية الأساسية. » ضمان توفر ما يلي: على الأقل دواء واحد مضاد للذهان )في شكل قرص وأشكال قابلة للحقن( على الأقل دواء واحد لعلاج مرض باركنسون )لمعالجة الآثار الجانبية خارج الهرمية* stceffe edis ladimarypartxe( المحتملة )في شكل قرص( على الأقل دواء واحد مضاد للصرع / مضاد للاختلاج )في شكل قرص( على الأقل دواء واحد مضاد للاكتئاب )في شكل قرص( وعلى الأقل دواء واحد مضاد للقلق )في شكل قرص وأشكال قابلة للحقن(. » يمكنك الحصول على المجموعة الصحية المشتركة بين الوكالات لحالات الطوارئ )KHEI( )منظمة الصّحة العالمية، 1102(، وهي عبارة عن صندوق كبير يحتوي على الأدوية والمعّدات الطبية المصّممة لتلبية حاجات الرعاية الصحية الأّولية المتوقّعة لعشرة آلاف شخص مع رضين لطوارئ إنسانية رئيسية لمدة ثلاثة أشهر. تحتوي مجموعة KHEI على الأدوية النفسانيّة التأثير التالية: – أقراص الاميتريبتيلين: قرص 5۲ ملغم × 000٤ – أقراص البيبيريدين: قرص ۲ ملغم × 00٤ – أقراص الديازيبام: قرص 5 ملغم × 0٤2 – حقن الديازيبام: 5 ملغم / مل، ۲ مل / الامبولة × 002 – أقراص الهالوبيريدول: قرص 5 ملغم × 0031 – حقن الهالوبيريدول: 5 ملغم / مل، 1 مل / الامبولة × 02 – أقراص الفينوباربيتال: ∙ 5 ملغم × 0001 إن كمية الأدوية ضمن مجموعة KHEI لا تكفي للبرامج الاستباقية التي تعمل على تقّص وتدبير حالات الصرع والذهان والاكتئاب. يجب عندئذ طلب المزيد من الأدوية. على المدى الطويل، تصبح الكميات الضرورية من الأدوية معروفة من خلال الاستعمال الفعلي ويتم التبليغ عنها. » بالإضافة إلى الأدوية النفسانيّة التأثير، يجب توفر الاتروبين للمعالجة السريرية للتسّمم الحاد بالمبيدات، وهو شكل تقليدي من إيذاء الذات. الاتروبين متوفر داخل مجموعة KHEI )1ملغم / مل، 1 مل / الامبولة × 05( » التأكد من أن كافة الأدوية محفوظة بشكل آمن. إدارة المعلومات » ضمان الّسرية. الاحتفاظ بالملفات الصحية بشكل آمن. » تحديد البيانات الواجب إدخالها في نظام المعلومات الصحية. النظر في استخدام تصنيف الاضطرابات العصبية النفسية ضمن سبع فئات لنظام المعلومات الصحية الخاص بالمفوضية السامية للأمم المتحدة لشؤون اللاجئين والاستناد عليه في توثيق الاضطرابات النفسية والعصبية واستخدام مواد الإدمان )راجع الملحق 1( في حالات الطوارئ الشديدة الواسعة النطاق، قد لا يكون صانعو القرار في مجال الصّحة العامة على استعداد لإضافة سبعة عناصر لنظام المعلومات الصحية. في تلك الحالة، يجب على الأقل إضافة عنصر واحد يحمل عنوان "المشاكل النفسية أو العصبية أو استخدام مواد الإدمان" إلى نظام المعلومات الصحية. مع الوقت، يجب استبدال هذا العنصر بنظام أكثر تفصيلا.ً » جمع البيانات وتحليلها وابلاغ النتائج لصانعي القرار المعنيين في مجال 4الصّحة العامة. المبادئ العامة لرعاية الأشخاص ذوي الاضطرابات النفسية والعصبية واستخدام مواد الإدمان في مواقع الطوارئ الإنسانية 1. مبادئ التواصل في البيئات الإنسانية السريعة التغّير وغير المتوقعة، يخضع مقّدمو الرعاية الصحية لضغوطات هائلة سعيا ًلتلبية حاجات أكبر عدد ممكن من الأشخاص في أقل وقت ممكن. كما يجب أن تكون الاستشارات داخل المرافق الصحية مختصرة، مرنة ومتمحورة حول المسائل الأكثر إلحاحا.ً لذلك فإن مهارات التواصل الجيّدة ستساعد مقّدمي الرعاية الصحية على تحقيق هذه الأهداف وتقديم الرعاية الفّعالة للبالغين والمراهقين والأطفال المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان. » ايجاد بيئة تسّهل التواصل الصريح إن أمكن، مقابلة الشخص داخل حّيز خاص. جعل مستوى عينيك بموازاة عيني الشخص )على سبيل المثال، إذا كان الشخص جالسا،ً اجلس أنت أيضا(ً. الترحيب بالشخص، تقديم نفسك ومركزك / دورك بطريقة ملائمة من الناحية الثقافية. التعريف بكل شخص موجود. سؤال الشخص عن رغبته أو رغبتها ببقاء القائمين على العناية به أو بها أو غيرهم من الأشخاص في الغرفة. – التعبير عن رغبتك في التحدث مع الشخص على انفراد إن أمكن، إلا إذا كان طفلاً صغيرا.ً إن رغب الشخص ببقاء الأشخاص الآخرين، يجب احترام ذلك. – في حال مقابلة الشخص على انفراد، طلب الإذن منه: – لطرح الأسئلة التقييمية ذات الصلة على القائمين على العناية به للاطلاع على وجهة نظرهم، – لإشراك القائمين على العناية به عند مناقشة خطة التدبير العلاجي والموافقة عليها. إبلاغ الشخص أّن المعلومات التي تمّت مناقشتها خلال الزيارة ستبقى سريّة ولن يطلع أحد عليها من دون موافقته، إلا في حال الشعور بخطر على الشخص أو الغير )تجدر الإشارة الى أن هذه النقطة قد تحتاج إلى تعديل وفقا للحدود القانونية الوطنية للسريّة(. » إشراك الشخص المصاب باضطراب نفسي أو عصبي أو استخدام مواد إدمان قدر الإمكان محاولة إشراك الشخص في النقاش دوما ًولو كان مصابا ًبخلل وظيفي. ينطبق ذلك أيضا ًعلى الأطفال والشباب والمسّنين المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان. لا يجدر تجاهلهم بمخاطبة القائمين على العناية بهم فقط. محاولة شرح ما تفعله للشخص دوما ً)مثلاً خلال الفحص البدني( وما تنوي القيام به. » البدء بالاستماع إتاحة الفرصة للشخص المصاب باضطراب نفسي أو عصبي أو استخدام مواد إدمان للتكلم من دون مقاطعة. إّن الأشخاص الذين يكونون في حال ضيق قد لا يعبرون دوما بصورة واضحة. عند حصول ذلك، التحّلي بالصبر وطلب التوضيحات. عدم محاولة حّث الشخص على الإسراع. عدم الضغط على الشخص لمناقشة أو وصف أحداث قادرة على التسبّب بصدمة* )stneve citamuart yllaitnetop( إن لم يبِد رغبة في الإفصاح عنها. ببساطة دعه يشعر بأنك هنا للاستماع إليه. قد يحتاج الأطفال إلى مزيد من الوقت للشعور بالارتياح. يجب استخدام لغة يسهل عليهم فهمها. لإنشاء علاقة مع الأطفال، ربما يتطلّب ذلك التحدث معهم عن اهتماماتهم )الألعاب، الأصدقاء، المدرسة، إلخ(. » توخي الوضوح والاختصار استخدام لغة يألفها الشخص. تجّنب استعمال المصطلحات التقنية. إن الضغط النفسي من شأنه أن يضعف قدرة الشخص على استيعاب المعلومات ومعالجتها. يجب طرح نقطة تلو الأخرى لمساعدة الشخص على فهم ما يُقال قبل الانتقال إلى النقطة الثانية. تلخيص النقاط الأساسية وتكرارها. من المفيد ربما الطلب من الشخص أو من القائمين على العناية به تدوين النقاط المهمة أو عوضا ًعن ذلك تزويد الشخص بملخص مكتوب بالنقاط الأساسية. » الاستجابة بتعاطف حين يفصح لك الأشخاص عن تجارب مؤلمة (كاعتداء جنسي أو عنف أو إيذاء الذات) إعلام الشخص بأنك ستحترم سرية المعلومات. عدم الاستخفاف أبدا ّبمشاعر الشخص، عدم الوعظ أو إصدار الأحكام. الاعتراف بصعوبة ما يشاركك به الشخص. إن كان لا بّد من إحالة الشخص إلى خدمات أخرى، الشرح له بوضوح الخطوات التالية الواجب القيام بها والطلب منه الموافقة على مشاركة هذه المعلومات مع مقّدمي خدمات صحية آخرين يمكنهم تقديم المساعدة. على سبيل المثال: 5 – لقد قلت لي أن جارك قد أساء إليك جدا.ً أنا لن أبوح بهذه المعلومات لأحد، لكنني أعتقد أنني أعرف بعض الأشخاص القادرين على مساعدتك. فهل توافق أن أناقش تجربتك مع زميلي من الوكالة X؟ » عدم الحكم على الأشخاص من خلال سلوكهم إن الأشخاص المصابين باضطرابات نفسية وعصبية واستخدام مواد إدمان حادة قد يتصرفون بشكل يبدو غريبا ًأو غير اعتيادي. يجب الإدراك أن هذا السلوك قد يكون ناشئا ًعن مرضهم. المحافظة على الهدوء والتحلي بالصبر. عدم الاستهزاء بهم أبدا.ً – إذا كان سلوك الشخص غير ملائم )إن كان منفعلاً، عدائيا،ً متوّعدا(ً، ابحث عن سبب المشكلة واقترح الحلول. إشراك القائمين على العناية به أو موظفين آخرين لخلق السكينة والهدوء داخل المكان. إن اعترت الشخص حالة من الهياج أو الضيق الشديد، قد تحتاج لمنح هذه الاستشارة الأولوية واستدعاء الشخص إلى مكان الاستشارة في الحال. » عند الضرورة، الاستعانة بالمترجمين الشفهيين الملائمين عند الضرورة، محاولة العمل مع مترجمين متمرّسين، ومن الأفضل أن يكون المترجم من نفس جنس الشخص المصاب باضطراب نفسي أو عصبي أو استخدام مواد إدمان. في حال عدم توفر مترجم متمرّس، من الممكن أن يتولى موظفون آخرون من طاقم الرعاية الصحية أو القائمون على العناية بالشخص عملية الترجمة الشفهية بموافقة الشخص. إذا تولى القائم على العناية بالشخص عملية الترجمة، التنبّه إلى أن الشخص قد لا يفصح بشكل كامل عّما في داخله. فضلاً عن أن تضارب المصالح بين الشخص والقائم على العناية به قد يؤثر في عملية التواصل. إن شّكل الأمر مشكلة، يجب توافر مترجم مناسب للزيارات المقبلة. إبلاغ المترجم بضرورة احترام السرية ومراعاة الترجمة الحرفية من دون إضافة الأفكار والتأويلات الخاصة به. 6 » استعراض الشكوى المعروضة ما الذي أتى بك إلى هنا؟ متى وكيف بدأت المشكلة؟ كيف تطّورت مع الوقت؟ ما شعورك حيال هذه المشكلة؟ ما مصدرها بحسب اعتقادك؟ كيف تؤثر هذه المشكلة في حياتك اليومية؟ كيف تؤثر هذه المشكلة في دراستك / عملك أو في حياتك اليومية ضمن المجتمع؟ بأي طريقة حاولت حل هذه المشكلة؟ هل جّربت أي دواء؟ في حال الإيجاب، ما نوع الدواء )على سبيل المثال، موصوف، غير موصوف، عشبي(؟ ما كانت تأثيراته عليك؟ » استعراض التاريخ العائلي المحتمل للاضطرابات النفسية والعصبية واستخدام مواد الإدمان هل يعاني أي فرد من أسرتك من مشكلة مماثلة؟ » استعراض التاريخ الصحي العام للشخص الاستعلام عن أية مشكلة صّحية بدنية سابقة: – هل أصبت في الماضي بأية مشكلة صّحية خطيرة؟ – هل تعاني حاليا ًمن أية مشكلة صّحية تتلقى علاجا ًلها؟ سؤال الشخص عّما إذا كان يتناول أي دواء: – هل وصف لك مقّدم رعاية صحية أي دواء من المفترض أنك تتناوله حالياً؟ – ما اسم هذا الدواء؟ هل أحضرته معك؟ كم مرّة تتناوله؟ سؤال الشخص عن حساسية سابقة لأي دواء. » استعراض الضغوطات الحالية واستراتيجيات التأقلم والدعم الاجتماعي كيف تغّيرت حياتك منذ ...[أذكر الحدث الذي سبّب الأزمة الإنسانية]؟ هل خسرت شخصا عزيزاً؟ كم شّدة الضغط النفسي في حياتك؟ كيف يؤثر فيك؟ ما هي مشاكلك الأكثر أهمية حالياً؟ كيف تواجه / تتعامل مع هذه المشاكل يوما بعد يوم؟ ما نوع الدعم الذي تحظى به؟ هل تحصل على المساعدة من أسرتك أو أصدقائك أو الأشخاص ضمن مجتمعك؟ » استعراض أي تعاٍط محتمل للكحول ومواد الإدمان إن الأسئلة بشأن الكحول ومواد الإدمان قد تعتبر محرجة وحتى جارحة، إلا أنها مكّون أساسي لتقييم الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. الشرح للشخص بأنها جزء من التقييم ومحاولة طرح الاسئلة بطريقة تراعي الخصوصيات الثقافية ولا تنّم عن أحكام. أوّد أن أطرح عليك بعض الأسئلة الروتينية كجزء من التقييم. هل تشرب الكحول )أو تستهلك أية مادة أخرى يُعرف أنها تشكل مشكلة في المنطقة(؟ [في حال الإيجاب]كم مرة في اليوم / الأسبوع؟ هل تتناول أية أقراص عندما تشعر بالتوتر أو الضيق أو الخوف؟ ماذا تستخدم عندما تشعر بالألم؟ هل تتناول الأقراص المنّومة؟ [في حال الإيجاب] كم مرة في اليوم / الأسبوع وما كميتها؟ منذ متى؟ » استعراض أية أفكار ومحاولات انتحار إن الأسئلة بشأن الانتحار قد تعتبر جارحة أيضا،ً لكنها أسئلة أساسية أيضا في تقييم الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. محاولة طرح الاسئلة بطريقة تراعي الخصوصيات الثقافية ولا تنّم عن أحكام. من الممكن البدء بالسؤال التالي: ما هي آمالك للمستقبل؟ إن عّبر الشخص عن شعور باليأس، طرح أسئلة إضافية (>> المربع 1 من الوحدة الخاصة بالانتحار IUS)، مثلا هل تشعر بأن الحياة تستحق العيش؟ هل تفكر بإلحاق الأذى بنفسك؟ أو هل وضعت خططا ً لوضع حّد لحياتك؟ )>> IUS( » إجراء فحص بدني مستهدف يجب أن يكون الفحص البدني مركّزا ًوموجها يستند على المعلومات التي تّم جمعها خلال تقييم الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. في حال إيجاد أية حالة مرّضية بدنية في هذه المرحلة، يجب علاجها أو إحالته إلى الموارد المختّصة. ۲. مبادئ التقييم ينّص التقييم السريري على تحديد الاضطراب النفسي والعصبي واستخدام مواد الإدمان وعلى استكشاف استيعاب الشخص لمشكلته أو لمشاكله. من الضروري أيضا تقييم قدرات الشخص وموارده )كالدعم الاجتماعي(. هذه المعلومات الإضافية ستتيح لمقّدمي الرعاية الصحية توفير رعاية أفضل. خلال التقييم، من المهم التنبّه دوما ًإلى المظهر العام للشخص المُصاب باضطراب نفسي أو عصبي أو استخدام مواد إدمان، إلى مزاجه، تعابير وجهه، لغة جسده وحديثه. » في حال الاشتباه باضطراب نفسي أو عصبي أو استخدام مواد إدمان، مراجعة الوحدة المعنيّة من أجل التقييم. » إذا كانت تبدو على الشخص سمات تشير إلى أكثر من اضطراب واحد نفسي أو عصبي أو استخدام مواد إدمان، يجب عندئذ مراجعة كافة الوحدات ذات الصلة. 7 ۳. مبادئ التدبير الكثير من الاضطرابات النفسية والعصبية واستخدام مواد الإدمان هي اضطرابات مزمنة تتطلب المراقبة والمتابعة على المدى الطويل. لكن في مواقع الطوارئ الإنسانية، قد تتعثر استمرارية الرعاية نظرا ًلأن الرعاية الصحية النفسية لا تتوفر باستمرار أو لأّن السكان قد نزحوا أو هم على وشك النزوح. لذا فمن الضروري الإقرار بأهمية القائمين على العناية بالأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان كموارد قيّمة، فهم قادرون على توفير الرعاية المستمرة والدعم والمراقبة على امتداد الأزمة. أولئك القائمون على العناية بالأشخاص يضّمون كل من يشترك في تأمين رفاه الشخص المصاب باضطراب نفسي أو عصبي أو استخدام مواد إدمان، بما في ذلك الأسرة أو الأصدقاء أو أشخاص آخرون موثوقون. إن زيادة قدرة الشخص والقائم على العناية به على استيعاب الاضطراب النفسي والعصبي واستخدام مواد الإدمان، فضلاً عن خطتي التدبير العلاجي والمتابعة ستعزز الالتزام بالعلاج. » معالجة الاضطرابات النفسية والبدنية عند الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان توفير المعلومات للشخص عن حالته – إن وافق الشخص، إبلاغ هذه المعلومات أيضا ًللقائم على العناية به. تحديد الأهداف القابلة للتحقيق ومناقشتها ووضع خطة لتدبير أو لعلاج الحالة والموافقة عليها بالتعاون مع الشخص – إن وافق الشخص، إشراك القائم على العناية به أيضا ًفي هذا النقاش – بالنسبة إلى خطة التدبير العلاجي المقترحة، توفير المعلومات بشأن الآتي: الفوائد المتوقعة للعلاج مّدة العلاج أهمية الالتزام بالعلاج، بما في ذلك ممارسة أية تدخلات نفسية ذات صلة )كالتدرّب على الاسترخاء( في المنزل، وكيفية مساهمة القائمين على العناية بالشخص في ذلك؛ الآثار الجانبية المحتملة لأي دواء موصوف؛ المساهمة المحتملة للأخصائيين الاجتماعيين، مدراء الحالات، العاملين الصحيين المحليين أو أفراد آخرين موثوقين ضمن المجتمع )>> مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي أدناه(؛ التوقعات المرّجحة لسير الحالة. خاطب الشخص بتفاؤل ولكن كن واقعيا في ما يخص الشفاء. توفير المعلومات عن الجوانب المالية لخطة التدبير، إن توّجب الأمر. » التعامل مع أسئلة ومخاوف الشخص والقائم على العناية به المتعلقة بخطة التدبير » قبل مغادرة الشخص التأكّد من أن الشخص والقائم على العناية به مدركان لخطة تدبير الحالة وموافقان عليها )كأن تطلب منهما تكرار النقاط الأساسية للخطة(. تشجيع الشخص على المراقبة الذاتية للأعراض وتثقيف الشخص والقائم على العناية به بشأن الأعراض التي تستوجب الحصول على الرعاية الفورية. تحديد زيارة متابعة. – وضع خطة متابعة، مع الأخذ بعين الاعتبار الأوضاع الإنسانية السائدة )السكان النازحون/الهاربون واختلال الخدمات(. – إن تعّذر على الشخص الوصول إلى العيادة نفسها: تزويد الشخص بخطة تدبير علاجي مكتوبة موجزة وتشجيعه على حمل هذه الخطة في زياراته المقبلة لأي عيادة. توفير معلومات الاتصال الخاصة بمرافق الرعاية الصحية المجاورة الأخرى. يجب أن تكون زيارات المتابعة الأّولية أكثر تواترا ًإلى أن تبدأ الأعراض بالاستجابة للعلاج. ما أن تبدأ الأعراض بالتحّسن، ينصح بمواعيد منتظمة أقل تواترا.ً الشرح للشخص أن بإمكانه العودة إلى العيادة في أي وقت بين زيارات المتابعة إن دعت الحاجة )مثلا ًعند الشعور بآثار جانبية للدواء(. » في كل زيارة متابعة، تقييم ما يلي: الاستجابة للعلاج، الآثار الجانبية للدواء، الالتزام بتناول الدواء والتدخلات النفسية الاجتماعية. التنويه بكل تقّدم محرز باتجاه تحقيق الأهداف وتعزيز الالتزام. الوضع الصحي العام. مراقبة الصّحة البدنية بانتظام. الرعاية الذاتية )كالنظام الغذائي، النظافة، الملابس( والأداء الوظيفي للشخص ضمن بيئته. المسائل النفسية الاجتماعية و/أو التغيرات في الأوضاع المعيشية التي يمكنها التأثير في تدبير الحالة. استيعاب الشخص والقائم على العناية به للعلاج وتوقعاتهما منه. تصحيح أي تصّور خاطئ. التحّقق دوما من أحدث معلومات الاتصال، إذ يمكن أن تتغير باستمرار. » خلال المّدة الكاملة للمتابعة: التواصل بشكل منتظم مع الشخص والقائم على العناية به. إن أمكن، تعيين عامل مجتمعي أو شخص آخر موثوق من المجتمع للبقاء على اتصال مع الشخص. من الممكن أن يكون هذا الشخص فردا ًمن الأسرة. الاحتفاظ بخطة عمل في حال تغيّب الشخص. – محاولة معرفة سبب عدم عودة الشخص. من الممكن أن يساعد عامل مجتمعي أو شخص موثوق آخر في تحديد مكان الشخص )من خلال زيارات منزلية(. – إن أمكن، محاولة حل المسألة بحيث أن يعاود الشخص زيارة العيادة. إن لم تتحّسن حالة الفرد، استشارة أخصائي. إذا كانت المرأة حاملا ًأو مرضعة: » تجّنب وصف الأدوية التي قد تشكل خطرا ًمحتملا ًعلى الجنين وتسهيل الوصول إلى الرعاية السابقة للولادة. » تجّنب وصف الأدوية التي قد تشكل خطرا ًمحتملا ًعلى رضيع/ طفل حديث المشي لامرأة مرضعة. راِقب طفل امرأة مرضعة تتناول الأدوية وانظر في تسهيل الوصول إلى الخيم/الأماكن 8الصديقة للأطفال. ٤. مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي إن تقليص الضغط النفسي وتعزيز الدعم الاجتماعي يشكلان جزءا ًلا يتجزأ من علاج الاضطرابات النفسية والعصبية واستخدام مواد الإدمان في مواقع الطوارئ الإنسانية التي يتعرّض فيها الأشخاص غالبا ًلمستويات عالية جدا ًمن الضغط النفسي، ولا نعني الضغط النفسي الذي يشعر به الأشخاص المصابون بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان فحسب اونما الضغط النفسي الذي يصيب أيضا ًالقائمين على العناية بهم وُمعاليهم. يساهم الضغط النفسي كثيرا ًفي هذه الاضطرابات أو يزيدها تفاقما.ً أما الدعم الاجتماعي فقادر على تقليص العديد من التأثيرات السلبية للضغط النفسي، لذا لا بّد من إيلائه الأهمية اللازمة. إّن تعزيز الدعم الاجتماعي يشّكل أيضا ًمكّونا أساسيا ًمن الحماية )>> مبادئ حماية حقوق الإنسان( والرفاه العام للسكان المتأثرين بالأزمات الإنسانية )>> مبادئ التنّبه للرفاه العام(. » استعراض الضغوطات المحتملة وتوافر الدعم الاجتماعي ما يقلقك كثيرا ًفي هذه الأيام؟ كيف تتعامل مع هذا القلق؟ ما هي الأمور التي تمنحك الراحة والقوة والطاقة؟ لمن ترتاح أكثر في الإفصاح عن مشاكلك؟ عندما تشعر بالضيق، لمن تتوّجه من أجل المساعدة أو النصح؟ كيف تصف علاقتك بأسرتك؟ كيف يدعمك أصدقاؤك وأسرتك وكيف يمكنهم أن يشكلوا مصدرا ًللتوتر بالنسبة إليك؟ » الانتباه لعلامات الإساءة أو الإهمال التنبّه لعلامات اعتداء جنسي أو جسدي محتملة )بما في ذلك العنف الأسري( لدى النساء والأطفال والمسنين (كالكدمات أو الإصابات غير المفّسرة، الإفراط في القلق، عدم الرغبة في مناقشة مسائل بحضور فرد من الأسرة(. التنبّه لعلامات إهمال محتملة، خاصة لدى الأطفال والأشخاص ذوي الإعاقات والمسّنين )على سبيل المثال، سوء تغذية داخل أسرة تتوفر لها إمكانية الحصول على الغذاء الكافي، طفل شديد الانزواء(. في حال وجود علامات اعتداء أو إهمال، مقابلة الشخص في مكان خاص للاستفسار عّما يسيء إليه. في حال الاشتباه بإهمال أو اعتداء: – إبلاغ المسؤول عنك فورا ًللتباحث معه في خطة عمل. – تحديد الموارد المجتمعية )كالخدمات القانونية الموثوقة وشبكات الحماية( للحصول على الحماية بموافقة الشخص. » بالاستناد إلى المعلومات التي تّم جمعها، النظر في الاستراتيجيات التالية: حل المشاكل: – استخدام تقنيات حل المشاكل* )gnivlos-melborp seuqinhcet( لمساعدة الشخص على التعامل مع الضغوطات الرئيسية. إن لم يكن بالإمكان إزالة الضغوطات أو تقليصها، يمكن اللجوء إلى تقنيات حل المشاكل لتحديد طرق التصّدي للضغوطات. بشكل عام، عدم تقديم النصح المباشر. محاولة تشجيع الشخص على إيجاد الحلول بنفسه. – عند التعامل مع الأطفال والمراهقين، من الضروري أيضا ًتقييم مصادر الضغط النفسي لدى القائمين على العناية بهم وتدبيرها. تعزيز الدعم الاجتماعي: – مساعدة الشخص على تحديد أفراد الأسرة والأصدقاء وأعضاء المجتمع الموثوقين والداعمين واستقصاء كيفية مساهمة كل منهم في بذل المساعدة. – إحالة الشخص إلى موارد مجتمعية أخرى للحصول على الدعم الاجتماعي وذلك بموافقته. قد يتمّكن الأخصائيون الاجتماعيون أو مدراء الحالات أو أشخاص موثوقون آخرون ضمن المجتمع من ربط الشخص بالموارد الملائمة مثل: الخدمات الاجتماعية أو خدمات الحماية المأوى والغذاء والمواد غير الغذائية لمراكز المجتمعية، مجموعات المساعدة الذاتية والدعم الأنشطة المدرّة للدخل والأنشطة المهنية الأخرى التعليم الرسمي/غير الرسمي الأماكن الصديقة للأطفال أو غيرها من الأنشطة المنهجية الموجهة للأطفال والمراهقين. عند الإحالة، مساعدة الشخص على الوصول إليها )إعطاء التوجيهات بالنسبة إلى الموقع، ساعات العمل، أرقام الهاتف، إلخ( وتزويد الشخص برسالة إحالة مقتضبة. تعليم كيفية التعامل مع الضغط النفسي: – تحديد أساليب استرخاء إيجابية وتطويرها )كالاستماع إلى الموسيقى، ممارسة الرياضة، الخ(. – تعليم الشخص والقائمين على العناية به تقنيات محّددة للتعامل مع الضغط النفسي )كتمارين التنفس )>> المربع 2CPG((. في بعض المواقع، يمكن إحالتهم إلى عامل صحي )كممرض أو أخصائي نفسي اجتماعي( قادر على تعليمهم هذه التقنيات. » التعامل مع الضغط النفسي لدى القائمين على العناية بالشخص سؤال القائم أو القائمين على العناية بالشخص بشأن: – التوتر والقلق الناجمين عن العناية بالشخص المصاب باضطراب نفسي أو عصبي أو استخدام مواد إدمان في حالة الطوارئ الإنسانية القائمة؛ – التحّديات العملية )كالأعباء الملقاة على كاهل القائمين على العناية بالشخص من حيث الوقت والحرية والمال(؛ – القدرة على مزاولة الأنشطة اليومية الأخرى، مثل العمل أو المشاركة في المناسبات ضمن المجتمع؛ – الإرهاق الجسدي؛ – الدعم الاجتماعي المتوفر للقائمين على العناية بالشخص: هل يستطيع أشخاص آخرون مساعدتك عندما تكون غير قادر على الاعتناء بالشخص (على سبيل المثال، عندما تكون مريضا أو مرهقا جدا)ً؟؛ 9 المربع 1CPG : تعزيز الدعم المجتمعي بالإضافة إلى المعالجة السريرية، تشجيع الأنشطة التي تعّزز الدعم المجتمعي والأسري للجميع، لاسّيما لأفراد المجتمع المهّمشين. لمزيد من التوجيهات، مراجعة فهم الحماية المجتمعية )المفوضية السامية للأمم المتحدة لشؤون اللاجئين، 3102( وورقة العمل 5،2 للمبادئ التوجيهية للجنة الدائمة المشتركة بين الوكالات بشأن الصحة النفسية والدعم النفسي الاجتماعي في حالات الطوارئ )CSAI، 7002(. المربع 2CPG : تمرين الاسترخاء: تعليمات بشأن تقنية التنفس البطيء سأعلمكم كيفية التنّفس بطريقة تساعدكم على الاسترخاء جسديا ًوعقليا.ً ستتطلب منكم هذه التقنية بعض الممارسة قبل الانتفاع كاملاً من فوائدها. تركّز هذه الاستراتيجية على التنفس لأنه عندما يكون المرء متوترا ًيصبح تنفّسه سريعا ًوضحلاً، فيزداد توتّره. للبدء بالاسترخاء، يجب تغيير طريقة التنفس. قبل البدء، سنعمد إلى إرخاء الجسد. القيام بهّز الذراعين والساقين بلطف وارخائها بحيث تصبح مرنة وليّنة. إرجاع الكتفين إلى الوراء وتحريك الرأس من جانب إلى آخر بلطف. وضع إحدى اليدين الآن على المعدة واليد الأخرى على أعلى الصدر. تخيّلوا أن في معدتكم بالونا ًوعند الشهيق ستنفخون هذا البالون بحيث أن المعدة تتوّسع. وعند الزفير، سيخرج الهواء من داخل البالون أيضا ًبحيث أن المعدة تتسطّح. راقبوني أولاً. سأبدأ بالزفير أولاً لإخراج الهواء من معدتي. [عرض كيفية التنفس من المعدة التجربة والمبالغة في الدفع داخل المعدة وخارجها] حسنا،ً لنحاول الآن التنّفس من المعدة سويّة. تذكروا نبدأ بالزفير لإخراج الهواء بالكامل ثم نقوم بالشهيق. إن أمكن، حاولوا إدخال الهواء من الأنف واخراجه من الفم. عظيم! الخطوة التالية هي إبطاء سرعة التنّفس. لذلك سندخل الهواء في ثلاث ثوان، نوقف التنفس ثانيتين ثم نخرج الهواء في ثلاث ثوان. سنقوم بالعّد سويّة. يمكنكم إغلاق العينين أو فتحهما. حسنا،ً شهيق 1، 2، 3. توقف 1، 2، 3. هل تلاحظون كم أنني أعّد ببطء؟ [تكرار تمرين التنّفس مدة دقيقة تقريبا]ً عظيم! عندما تتمرّنون وحدكم، لا تقلقوا بشأن دقة الالتزام بالثواني الثلاث. افعلوا ما بوسعكم فقط لإبطاء تنّفسكم عند الشعور بالتوتر. حسنا،ً حاولوا وحدكم الآن مدة دقيقة. – السلامة النفسية. إذا بدا القائمون على العناية بالشخص في حال من الضيق أو عدم الاستقرار، تقييم إصابتهم بالاضطرابات النفسية رالعصبية واستخدام مواد الإدمان )على سبيل المثال >> BUS ,PED.( بعد التقييم، محاولة تدبير حاجات القائمين على العناية بالشخص ومعالجة مخاوفهم. وقد يشمل ذلك: – توفير المعلومات؛ – ربط القائمين على العناية بالشخص بالخدمات المجتمعية وخدمات الدعم ذات الصلة؛ – مناقشة الرعاية المؤقتة، أي أن يتولى فرد آخر من الأسرة أو شخص مناسب رعاية الشخص بشكل مؤقت في حين أّن القائم الرئيسي على العناية بالشخص يأخذ فترة من الراحة أو يقوم بأنشطة مهّمة أخرى؛ – تقديم الإرشاد بحل المشاكل* )gnivlos-melborp gnillesnuoc( وتعليم كيفية التعامل مع الضغط النفسي؛ – تدبير أي اضط ا رب نفسي أو عصبي أو استخدام مواد إدمان تّم استكشافه لدى القائم على العناية بالشخص. التنويه بأن رعاية الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان عملية ُمجهدة، ولكن لا بّد من إبلاغ القائم على العناية بالشخص بأهمية الاستمرار في تقديم هذه الرعاية. وعلى الرغم من صعوبة الأمر، يتوّجب على القائمين على العناية بالشخص احتترام كرامة الأشخاص الذين يتولّون رعايتهم واشراكهم بقدر الإمكان في اتخاذ القرارات المتعلقة بحياتهم. 01 5. مبادئ حماية حقوق الإ نسان إن الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان الحاّدة يحتاجون إلى الحماية بسبب الخطر الشديد المحيط بهم من حيث انتهاكات حقوق الانسان، فغالبا ًما يواجهون صعوبة في الاعتناء بأنفسهم وبأسرهم فضلاً عن التمييز الذي يواجهونه في مجالات عديدة من الحياة، بما في ذلك العمل والإيواء والحياة الأسرية. وقد يصعب عليهم الحصول على المساعدات الإنسانية ويتعرّضون للإساءة والإهمال داخل أسرهم ويُحرمون في كثير من الأحيان من فرصة المشاركة في المجتمع مشاركة كاملة. كما أّن بعض الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان الحاّدة ربما لا يدركون أنهم يعانون من مشكلة تستوجب الرعاية والدعم. خلال حالات الطوارئ الإنسانية، قد يتعرّض الأشخاص المصابون بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان لمجموعة من انتهاكات حقوق الانسان، لاسيّما: » التمييز في الحصول على الحاجات الضرورية للبقاء مثل الطعام، والمياه، اولصرف الصحي، والمأوى، والخدمات الصحية، والحماية ودعم سبل العيش؛ » الحرمان من حقهم في ممارسة الأهلية القانونية؛ » انعدام الوصول إلى الخدمات التي تلبي حاجات محّددة لديهم؛ » الاعتداء الجنسي والجسدي، الاستغلال، العنف، الإهمال والاحتجاز التعّسفي؛ » الهجر أو الانفصال عن أسرهم خلال النزوح؛ » الهجر والإهمال ضمن الأوساط المؤسساتية. لسوء الحظ إن أنظمة الحماية المجتمعية وبرامج الإعاقة لا تلحظ دوما حماية الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان الحاّدة، لا بل إنها في بعض الأحيان تستثنيهم بشّدة. لذا لا بّد لمقّدمي الرعاية الصحية أن ينشطوا في المطالبة بحماية أولئك الاشخاص ويبذلوا كل جهد من أجل رأب الفجوة في هذا المجال. نذكر في ما يلي الإجراءات الأساسية المساِهمة في حماية الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان الذين يعيشون ضمن تجّمعات في مواقع الطوارئ الإنسانية. » إشراك الجهات المعنّية الرئيسية تحديد الجهات المعنيّة الرئيسية التي يجدر بها أن تدرك مسائل الحماية المرتبطة بالأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان، وهي تضم الجهات التالية: – الأشخاص المصابون بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان والقائمون على العناية بهم؛ – قادة المجتمع )على سبيل المثال، ممثلون منتخبون عن المجتمع، شيوخ المجتمع، المعلمون، رجال الدين، المعالجون التقليديون والروحانيون(؛ – المدراء في مختلف الدوائر )على سبيل المثال، الحماية/الأمن، الصحة، المأوى، المياه والصرف الصحي، الغذاء، التعليم، برامج دعم سبل العيش(؛ – المسؤولون عن خدمات الإعاقة )الكثير من خدمات الإعاقة تتغاضى بغير قصد عن الإعاقة نظرا ًلإصابة الشخص بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان(؛ – ممثلون عن مجموعات المجتمع المحلي )التجّمعات الشبابية أو النسائية( ومنظمات حقوق الإنسان؛ الشرطة والسلطات القانونية. تنظيم أنشطة نشر الوعي الموّج هة للجهات المعنيّة الرئيسية: – النظر في تنظيم حلقات عمل توجيهيّة حول الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. – التباحث مع الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان، اولقائمين على العناية بهم فضلاً عن دوائر الخدمات الاجتماعية وخدمات الإعاقة بشأن تصميم أنشطة نشر الوعي وتنفيذها. – في أثناء أنشطة نشر الوعي: تبديد المفاهيم الخاطئة والتثقيف بشأن الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان. التثقيف بشأن حقوق الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان، بما في ذلك التساوي في الحصول على المساعدات الإنسانية والحماية. إزالة التمييز بحق الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان. المطالبة بدعم القائمين على العناية بالأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان. » حماية حقوق الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان الحاّدة في مواقع الرعاية الصحية معاملة الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان دوما ًباحترام وصون كرامتهم. ضمان حصول الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان على الرعاية الصحية البدنية على غرار الأشخاص غير المصابين بتلك الاضطرابات. احترام حق الشخص في رفض الرعاية الصحية إلا إذا كان لا يملك القدرة على اتخاذ مثل هذا القرار )مراجعة الاتفاقيات الدولية الموقّعة(. عدم التشجيع على إحالة الشخص إلى الرعاية المؤسساتية. إذا كان الشخص داخل مؤسسة، الدفاع عن حقوقه ضمن إطار المؤسسة. » تعزيز دمج الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان الحاّدة داخل المجتمع 11 إن المبادئ العامة للحماية في إطار العمل الإنساني موصوفة في دليل اسفير )مشروع اسفير، 1102(. للمزيد من التوجيهات بشأن حماية الأشخاص داخل مؤسسات/مستشفيات الأمراض العقلية، مراجعة ورقة العمل 6.۳ للمبادئ التوجيهية للجنة الدائمة المشتركة بين الوكالات بشأن الصحة النفسية والدعم النفسي الاجتماعي في حالات الطوارئ )CSAI، 7002( المناشدة بدمج الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان في برامج دعم سبل العيش، ببرامج الحماية وغيرها من الأنشطة المجتمعية. المناشدة بدمج الأطفال المصابين بالصرع وبغيره من الاضطرابات النفسية والعصبية واستخدام مواد الإدمان في التعليم العام. المناشدة بدمج برامج الأطفال والبالغين المصابين بإعاقات ذهنية/ تأخر في النمو ضمن برامج دعم الإعاقة المجتمعية. المناشدة بالحفاظ على استقلالية الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان واعتمادهم على أنفسهم بقدر الإمكان. 21 ٦. مبادئ التنّبه للرفاه العام بالإضافة إلى الرعاية السريرية، يحتاج الأشخاص المصابون بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان لأشكال أخرى من الدعم من أجل رفاههم العام. هذا ينطبق تماما في مواقع الطوارئ الإنسانية التي غالبا ًما تختل فيها الخدمات الأساسية والبنى الاجتماعية والحياة الأسرية والأمن، ويواجه فيها الأشخاص المصابون بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان تحديات إضافية إلى جانب روتينهم اليومي والرعاية الذاتية الأساسية. لذا فإن دور مقّدمي الرعاية الصحية يتخطى الرعاية السريرية ليطال الدفاع عن الرفاه العام للأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان عبر مختلف القطاعات، كما هو مبّين في هرم المبادئ التوجيهية للجنة الدائمة المشتركة بين الوكالات )راجع الشكل 1CPG(. الشكل 1CPG . هرم تدخلات اللجنة الدائمة المشتركة بين الوكالات في مجال الصّحة النفسية والدعم النفسي الاجتماعي في حالات الطوارئ الإنسانية )تّم تكييفه مع الموافقة( » دعم الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان للوصول بشكل آمن إلى الخدمات الضرورية للبقاء والعيش الكريم )مثل المياه، والصرف الصحي، والمساعدات الغذائية، والمأوى، ودعم سبل العيش(. هذا يشمل: الإرشاد بشأن توفّر مثل هذه الخدمات وموقعها؛ الإحالة الناشطة والعمل مع القطاع الاجتماعي لربط الأشخاص بالخدمات الاجتماعية )كإدارة الحالات ضمن العمل الاجتماعي(؛ الإرشاد بشأن المسائل الأمنية عندما لا يدرك الشخص الأخطار التي تهّدد أمنه بشكل كاٍف. » منح الأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان الأولوية في الوصول إلى الأنشطة ذات الصلة، مثل مساعدة الأطفال المصابين بتلك الاضطرابات في الوصول إلى الأماكن الصديقة للأطفال. » دعم الصّحة البدنية العامة للأشخاص المصابين بالاضطرابات النفسية والعصبية واستخدام مواد الإدمان: ترتيب تقييم صحي وتلقيح منتظمين. الإرشاد بشأن الرعاية الذاتية الأساسية )التغذية، التمارين البدنية، الجنس الآمن، تنظيم الأسرة، الخ(. الرعاية الصحية النفسية السريرية )سواء من قبل موظفي الرعاية الصحية الأولية أو أخصائيي الصّحة النفسية( الدعم العاطفي والعملي الأساسي لأسر أو أفراد مختارين تنشيط الشبكات الاجتماعية الأماكن الداعمة الصديقة للأطفال الدفاع عن الممارسات الإنسانية الجيّدة: الخدمات الأساسية الآمنة، المناسبة على المستوى الاجتماعي والراعية لكرامة الشخص الخدمات السريرية الدعم النفسي الاجتماعي المُركز تعزيز الدعم الأسري والمجتمعي الاعتبارات الاجتماعية في نطاق الخدمات الأساسية والأمن 31 الكرب الحاد في حالات الطوارئ الإنسانية، يتعرّض البالغون والمراهقون والأطفال في كثير من الأحيان لأحداث قادرة على التسّبب بصدمة* (yllaitnetop stneve citamuart) من شأنها أن تثير لديهم مجموعة واسعة من ردود الفعل العاطفية والمعرفية والسلوكية والبدنية. على الرغم من أن معظم ردود الفعل تزول تلقائيا ًولا تتطّور إلى اضطراب نفسي إلا أنه من المحتمل أن يتوّجه الأشخاص ذوو ردود الفعل الحاّدة إلى المرافق الصحية طلبا ً للمساعدة. في الكثير من حالات الطوارئ الإ نسانية، يتعرّض الأشخاص لمجموعة متنوعة من الخسارات والأحداث القادرة على التسّبب بصدمة. لذا فمن الممكن أن يصابوا بالكرب الحاد والحزن معا.ً للكرب الحاد والحزن أوجه مشتركة من حيث الأعراض والتقييم والتدبير، إلا أنه قد تمّت تغطية الحزن في وحدة مستقلة (>> IRG). إثر حدث مستجّد قادر على التسّبب بصدمة، يتوّجب على الطبيب السريري أن يحّدد الآتي: » اضطراب الكرب ما بعد الصدمة (>> DSTP). إذا استمرت مجموعة مميزة من الأعراض )عيش التجربة من جديد، تجّنب، إحساس متصاعد بالخطر الراهن( أكثر من شهر بعد وقوع حدث قادر على التسبّب بصدمة وان كانت لا تزال تسبّب صعوبات هائلة في الأداء اليومي، ربما تكون حالة الشخص قد تطّورت إلى اضطراب الكرب ما بعد الصدمة. » المشاكل والاضطرابات التي يحتمل وقوعها بشكل أكبر بعد التعرّض لضغوطات (مثل أحداث قادرة على التسّبب بصدمة) ولكن من الممكن أن تقع أيضا ًفي غياب مثل هذا التعرّض. وهي تشمل: الاضطراب الاكتئابي المعتدل إلى الحاد )>> PED(، الذهان )>> YSP(، التعاطي الضار للكحول ومواد الإدمان )>> BUS(، الانتحار )>> IUS( وشكاوى الصّحة النفسية الهاّمة الاخرى )>> HTO(. » ردود الفعل غير الخطيرة على الصعيد السريري التي لا تستلزم معالجة سريرية. من بين كافة ردود الفعل، هذه أكثرها شيوعا.ً وهي تشمل ردود الفعل المؤقتة التي لا يسعى الأشخاص بسببها للحصول على المساعدة والتي لا تعيق أداءهم اليومي. في مثل هذه الحالات، يتوجب على مقّدمي الرعاية الصحية دعم الشخص ومساعدته على تلبية حاجاته ومواجهة مخاوفه ومراقبة ما إذا حصل التعافي الطبيعي المتوقّع. » الأعراض الشديدة للكرب الحاد (>> UCA). إن الأشخاص المصابين بهذه الأعراض قد يمّرون بطائفة واسعة من الشكاوى النفسية غير المحّددة والبدنية غير المفّسرة طبيا.ً وتشمل هذه الأعراض ردود الفعل الناجمة عن حدث قادر على التسبّب بصدمة استجّد في الشهر الماضي، يسعى الأشخاص بسببه للحصول على المساعدة أو أنه يسبّب صعوبات هائلة في الأداء اليومي، فضلاً عن أنه لا يتطابق مع معايير الحالات الأخرى التي يتطرق إليها هذا الدليل. تغطي هذه الوحدة تقييم الأعراض الشديدة للكرب الحاد وتدبيرها. 41 التقييم السؤال التقييمي 1: هل تعرّض الشخص مؤخرا ًلحدث قادر على التسّبب بصدمة؟ السؤال التقييمي ۲: إذا تعرّض الشخص لحدث قادر على التسّبب بصدمة خلال الشهر الماضي، فهل يعاني من الأعراض الشديدة للكرب الحاد؟ السؤال التقييمي ۳: هل يعاني الشخص من حالة مرضّية متزامنة؟ » سؤال الشخص عّما إذا تعرّض لحدث قادر على التسّبب بصدمة، وهو كل حدث مرّوع أو مهّدد للحياة كعنف جسدي أو جنسي )بما في ذلك العنف الأسري(، مشاهدة أعمال وحشية، إصابات أو حوادث كبرى. النظر في الأسئلة التالية: ما الضغط النفسي الشديد الذي عشته؟ هل كانت حياتك في خطر؟ هل مررت بتجربة مخيفة جدا ًأو مرّوعة أو جعلتك تشعر بضيق شديد؟ هل تشعر بالأمان في المنزل؟ » كم من الوقت مضى منذ هذا الحدث أو هذه الأحداث؟ » إذا تعرّض الشخص فعلاً لحدث قادر على التسبّب بصدمة خلال الشهر الماضي، الانتقال إلى السؤال التقييمي ۲. » إذا تعرّض الشخص لخسارة كبيرة )كموت شخص عزيز(، إجراء تقييم للحزن أيضا ً)>> IRG(. » إذا تعرّض الشخص لحدث قادر على التسبّب بصدمة منذ أكثر من شهر مضى، التفكير بحالات أخرى يتطرّق إليها هذا الدليل )>> PED DSTP ,YSP ,BUS(. » البحث عن أية حالات بدنية يمكنها أن تفّسر الأعراض وتدبيرها وفقا ً لذلك إن ُوجدت » البحث عن أي اضطراب نفسي وعصبي واستخدام مواد إدمان آخر (بما في ذلك الاكتئاب) يتطرّق إليه هذا الدليل بإمكانه تفسير الأعراض، وتدبيره وفقا لذلك إن ُوجد. » البحث عن: قلق بشأن تهديدات متعلقة بالحدث أو الأحداث الصادمة مشاكل في النوم مشاكل في التركيز كوابيس متكررة، ارتجاع* )kcabhsafl( أو ذكريات اقتحامية* )seiromem evisurtni( للأحداث، يصحبها شعور بالخوف الشديد أو الرعب. تجّنب متعّمد للأفكار أو الذكريات أو الأنشطة أو الأوضاع التي تذكّر الشخص بالأحداث )كأن يتجّنب الشخص التكلّم بالمسائل التي تذكّره بالأحداث، أو يتجّنب العودة إلى الأماكن التي حصلت فيها الأحداث( سرعة تهيّج أو انفعال؛ تخّوف شديد وتيّقظ للخطر أو إصدار ردود فعل قوية على الأصوات الصاخبة أو الحركات غير المتوقّعة شعور بالصدمة أو الذهول أو الخدر، أو عدم القدرة على الإحساس بشيء أية مشاعر )مثل البكاء المتكّرر، الغضب( أو أفكار مزعجة تغّير في السلوك مثل: – عدائية – عزلة وانسحاب اجتماعي – سلوك متهور لدى المراهقين – سلوك تراجعي* )ruoivaheb evisserger( مثل التبّول اللاإرادي، التعلق الزائد أو البكاء لدى الأطفال فرط تهوية )مثل تنفس سريع، ضيق نفس( شكاوى بدنية غير مفّسرة طبيا،ً مثل: – خفقان قلب، دّوار – صداع، أوجاع وآلام معّممة – أعراض انشقاقية متعلقة بالجسد )كالشلل غير المفّسر طبيا*ً )sisylarap denialpxenu yllacidem(، عدم القدرة على الرؤية أو النطق، "النوبات الكاذبة أو الوهمية"* )seruziesoduesp((. » إن إصابة الشخص بالأعراض الشديدة للكرب الحاد أمر محتمل إذا انطبقت المعايير التالية كافة على الشخص: حدث قادر على التسبّب بصدمة وقع منذ شهر تقريباً بدء الأعراض بعد وقوع الحدث صعوبات هائلة في الأداء اليومي بسبب الأعراض أو السعي للحصول على المساعدة بسبب الأعراض 51 خطة التدبير الأساسية 1. في كافة الأحوال: » توفير الدعم النفسي الاجتماعي الأساسي۳ الاستماع جيدا.ً عدم الضغط على الشخص للتكلم. سؤال الشخص عن حاجاته/حاجاتها ومخاوفه/مخاوفها. مساعدة الشخص على تلبية حاجاته الأساسية أو الحصول على الخدمات واقامة الروابط مع الأسرة وأشكال الدعم الاجتماعي الأخرى. حماية الشخص من أي أذى )إضافي(. » توفير الدعم النفسي الاجتماعي الإضافي كما هو موصوف في مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي )>> المبادئ العامة للرعاية(: التعامل مع الضغوطات النفسية الاجتماعية الحالية تعزيز الدعم الاجتماعي تعليم كيفية التعامل مع الضغط النفسي » تثقيف الشخص بشأن ردود الفعل الطبيعية نتيجة الحزن والكرب الحاد، مثلاً: تكون ردود فعل الأشخاص غالبا ًبهذا الشكل بعد وقوع مثل تلك الأحداث. في معظم الحالات، تخف ردود الفعل مع الوقت. » معالجة الحالات المرضيّة المتزامنة » الشرح بأن الأشخاص يعانون بشكل عام من مشاكل في النوم )الأرق( بعد التعرّض لضغط نفسي شديد. » تقص الأسباب البيئية للأرق )مثل الضوضاء( ومعالجتها. » تقص أي سبب بدني للأرق)مثل الألم البدني( ومعالجته. » نصائح بشأن المبادئ الأساسية للنوم الصحي، بما في ذلك عادات النوم المنتظمة )على سبيل المثال، أوقات منتظمة للخلود إلى النوم والاستيقاظ(، تجّنب القهوة والنيكوتين والكحول في ساعات متأخرة من اليوم أو قبل الخلود إلى النوم. التشديد على أن الكحول تسبّب اضطرابات في النوم. » استثنائيا،ً في الحالات الشديدة الحّدة حيث لا تكون التدخلات الموّجهة نفسيا ً)مثل تقنيات الاسترخاء( متيسرة أو فّعالة وحيث الأرق يسبّب صعوبات هائلة في الأداء اليومي، التفكير في استخدام البنزوديازيبين كعلاج قصير الأجل )3-7 أيام(. الجرعة: – للبالغين، وصف ۲ – 5 ملغم من الديازيبام عند النوم. – للمسّنين، وصف1 – ۲،5 ملغم من الديازيبام عند النوم. – التحقق من التفاعلات بين الأدوية قبل وصف الديازيبام. – إن الآثار الجانبية الشائعة للبنزوديازيبين تشمل النعاس وضعف العضلات. – تحذير: البنزوديازيبين يمكنه إبطاء التنفس. قد تكون المراقبة المنتظمة ضرورية. – تحذير: البنزوديازيبين قد يسبّب الاعتماد* )ecnedneped(. يجب استعماله كعلاج قصير الأجل فحسب. تجدر الإشارة إلى ما يلي: – هذا العلاج هو للبالغين فقط. – عدم وصف البنزوديازيبين للأطفال أو المراهقين. – تجّنب هذا الدواء للنساء الحوامل أو المرضعات. – مراقبة الآثار الجانبية باستمرار عند استخدام هذا الدواء للمسّنين. – هذا حل مؤقت لمشكلة في النوم شديدة الحّدة. – لا يجب استخدام البنزوديازيبين لمعالجة الأرق الناجم عن فقدان شخص عزيز لدى البالغين أو الأطفال. – لا يجب استخدام البنزوديازيبين لمعالجة أعراض أخرى للكرب الحاد أو اضطراب الكرب ما بعد الصدمة. ۲. إن كانت المشاكل في النوم من أعراض الكرب الحاد، توفير التدبير الإضافي التالي: »عدم وصف الأدوية لمعالجة أعراض الكرب الحاد (ما لم يذكر غير ذلك أدناه). 61OHW ,IVW ,FTW۳ الأسلوب الموصوف هنا يُشار إليه غالبا ًبالإسعافات النفسية الأولية )AFP( عند تطبيقه فور وقوع حدث عصيب جدا ً)>> -3102(. » الحصول على تاريخ التبّول اللاإرادي للتأكد من أنه بدأ بعد حصول حدث عصيب. استبعاد الأسباب الممكنة الأخرى )مثل التهاب المسالك البولية( ومعالجتها عند الاقتضاء. » شرح: التبّول اللاإرادي هو رد فعل شائع غير مؤٍذ للأطفال الذين يعانون من الكرب. لا يجب معاقبة الأطفال بسبب تبّولهم اللاإرادي لأن العقاب يزيد توتّر الطفل ويمكنه أن يزيد المشكلة سوءا.ً يجب أن يتجّنب القائم على العناية بالطفل إحراجه بذكر التبّول اللاإرادي أمام الغير. يجب أن يحافظ القائم على العناية بالطفل على هدوئه ويكون داعما للطفل على الصعيد العاطفي. » النظر في تدريب القائمين على العناية بالأطفال على استخدام التدخلات السلوكية البسيطة )على سبيل المثال، مكافأة تفادي شرب الكثير من السوائل قبل النوم، مكافأة استخدام المرحاض قبل النوم، مكافأة الليالي الجافة بلا بلل(. يمكن أن تكون المكافأة أي شيء يحبّه الطفل كوقت لعب إضافي، نجوم على جدول أو ما يعادلها محليا.ً » استبعاد الأسباب الممكنة الأخرى ومعالجتها عند الاقتضاء، حتى لو بدأ فرط التهوية فور وقوع حدث عصيب. إجراء الفحوص الطبية الضرورية دوما ًلتحديد الأسباب البدنية الممكنة كداء الرئة. » إن لم يتم تحديد سبب بدني، طمأنة الشخص بأن فرط التهوية يحدث أحيانا بعد التعرّض لضغط نفسي شديد وأنه من المستبعد أن يشكل مشكلة طبية خطيرة. » المحافظة على الهدوء وإزالة المصادر المحتملة للقلق إن أمكن. مساعدة الشخص على استعادة تنّفسه الطبيعي بممارسة التنّفس البطيء )>> مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي ضمن المبادئ العامة للرعاية( )عدم اقتراح التنّفس داخل كيس ورق(. » استبعاد الأسباب الممكنة الأخرى ومعالجتها عند الاقتضاء، حتى لو بدأت الأعراض فور وقوع حدث عصيب. إجراء الفحوص الطبية الضرورية دوما ًلتحديد الأسباب البدنية الممكنة. مراجعة وحدة الصرع من أجل الإرشادات بشأن الفحوص الطبية المتعلقة بالصرع/ النوبات)>> IPE(. » الاعتراف بمعاناة الشخص وإظهار الاحترام المستمر. تفادي التشديد على أية فائدة قد يحصل عليها الشخص من الأعراض. » سؤال الشخص عن تفسيره الشخص للأعراض وتطبيق التوجيهات العامة المتعلقة بمعالجة الأعراض البدنية غير المفّسرة طبيا ً)>> HTO(. » طمأنة الشخص بأّن هذه الأعراض قد تنشأ أحيانا ًبعد التعرّض لضغط نفسي شديد وأنه من المستبعد أن تشكل مشكلة طبية خطيرة. » النظر في استخدام التدخلات المناسبة ثقافيا ًغير المؤذية. ۳. إن كان التّبول اللاإرادي عند الأطفال من أعراض الكرب الحاد، توفير التدبير الإضافي التالي: ٤. إن كان فرط التهوية (تنّفس متسارع جدا ًتتعذر السيطرة عليه) من أعراض الكرب الحاد، توفير التدبير الإضافي التالي: 5. إن كان عارض انشقاقي مرتبط بالجسد (كالشلل غير المفّسر طبيا،ً عدم القدرة على الرؤية أو النطق، "النوبات الكاذبة") من أعراض الكرب الحاد، توفير التدبير الإضافي التالي: ٦. الطلب من الشخص العودة بعد أسبوعين إلى أربعة أسابيع إن لم تتحّسن الأعراض، أو في أي وقت إذا ازدادت الأعراض سوءا.ً 71 الحزن في حالات الطوارئ الإنسانية، يتعرّض البالغون والمراهقون والأطفال في أحيان كثيرة لخسارة كبيرة والحزن هو تعبير عن ضيق عاطفي يشعر به الأشخاص بعد الخسارة. على الرغم من أن معظم ردود الفعل الناجمة عن الخسارة تتلاشى تلقائيا ًدون أن تتطّور إلى اضطراب نفسي، إلا أن الاشخاص الذين يعانون من أعراض حزن شديدة يميلون أكثر للتوّجه إلى المرافق الصحية سعيا ًللحصول على المساعدة. بعد التعرّض لخسارة، يتوّجب على الطبيب السريري أن يحّدد الآتي: » اضطراب الحزن الطويل الأَمد. إذا استمرت أعراض الحزن الشديدة لفترة مطّولة من الزمن، قد يُصاب الأشخاص باضطراب الحزن الطويل الأمد، وهو حالة تتّصف بانغماس عميق بالشخص المتوفي أو بشوق شديد إليه مصحوب بمشاعر أليمة مبرحة وبصعوبات هائلة في الأداء اليومي تمتد لفترة 6 أشهر على الأقل )ولفترة أطول بكثير مما هو متوقع ضمن ثقافة الشخص(. في هذه الحالات، يتوّجب على مقّدمي الرعاية الصحية استشارة أخصائي. » المشاكل والاضطرابات التي يحتمل وقوعها بشكل أكبر بعض التعرّض لضغوطات (كفقدان شخص عزيز) ولكن من الممكن أن تقع أيضا ًفي غياب مثل هذا التعرّض. وهي تشمل: الاضطراب الاكتئابي المعتدل إلى الحاد )>> PED(، الذهان )>> YSP(، التعاطي الضار للكحول ومواد الإدمان )>> BUS(، الانتحار/ إيذاء الذات )>> IUS( وشكاوى الصحة النفسية الهامة الأخرى )>> HTO(. » ردود الفعل غير الخطيرة على الصعيد السريري التي لا تستلزم معالجة سريرية. من بين كافة ردود الفعل، هذه أكثرها شيوعا.ً وهي تشمل ردود الفعل المؤقتة التي لا يسعى الأشخاص بسببها للحصول على المساعدة والتي لا تعيق أداءهم اليومي أبعد مما هو متوقع ثقافيا.ً في مثل هذه الحالات، يتوجب على مقّدمي الرعاية الصحية دعم الشخص ومساعدته على تلبية حاجاته ومواجهة مخاوفه ومراقبة ما إذا حصل التعافي الطبيعي المتوقّع. إلا أّن مثل ردود الفعل هذه لا تستدعي معالجة سريرية. » الأعراض الشديدة للحزن (>> IRG) على غرار أعراض الكرب الحاد، إّن الأشخاص الحزينين قد يمّرون بطائفة واسعة من الشكاوى النفسية غير المحّددة والبدنية غير المفّسرة طبيا.ً إثر التعرّض لخسارة، من الممكن أن تشتّد أعراض الحزن إن سبّبت لهم هذه الأعراض صعوبات هائلة في الأداء اليومي )تتخطى ما هو متوقع ثقافيا(ً أو إذا طلبوا المساعدة بشأن هذه الأعراض. تغطي هذه الوحدة تقييم الأعراض الشديدة للحزن وتدبيرها. 81 التقييم السؤال التقييمي 1: هل تعرّض الشخص مؤخرا ًلخسارة كبيرة؟ السؤال التقييمي ۲: إذا تعرّض الشخص لخسارة كبيرة خلال الأشهر الستة الأخيرة٤، فهل يعاني من أعراض حزن شديدة؟ السؤال التقييمي ۳: هل يعاني الشخص من حالة مرضية متزامنة؟ » سؤال الشخص عّما إذا تعرّض لخسارة كبيرة. النظر في الاسئلة التالية: كيف تأثرت بالكارثة/النزاع؟ هل خسرت أفرادا ًمن أسرتك أو أصدقاء لك؟ منزلك؟ مالك؟ عملك أو سبل كسب رزقك؟ مجتمعك؟ كيف تأثرت بهذه الخسارة؟ هل ثمة أفراد من أسرتك أو أصدقاء لك مفقودون؟ » سؤال الشخص كم من الوقت مضى منذ الحدث أو الأحداث. » إذا تعرّض الشخص فعلاً لخسارة كبيرة خلال الأشهر الستة الأخيرة، الانتقال إلى السؤال التقييمي ۲. » إذا تعرّض الشخص لخسارة منذ أكثر من ستة أشهر أو لحدث قادر على التسبّب بصدمة منذ أكثر من شهر مضى، التفكير في حالات أخرى يتطرّق إليها هذا الدليل )>> PED ,DSTP ,YSP ,BUS( أو في اضطراب الحزن الطويل الأمد. » البحث عن: كآبة، قلق، غضب، يأس تحّسر وانهماك في الخسارة ذكريات اقتحامية* )seiromem evisurtni(، صور وأفكار عن الشخص المتوفي فقدان الشهية انعدام الطاقة مشاكل في النوم مشاكل في التركيز عزلة وانسحاب اجتماعي شكاوى بدنية غير مفّسرة طبيا ً)مثل خفقان قلب، صداع، أوجاع وآلام معّممة( ردود فعل ناجمة عن الحزن ملائمة على المستوى الثقافي )مثل سماع صوت الشخص المتوفي، رؤية الشخص المتوفي في الأحلام(. » إن إصابة الشخص بالأعراض الشديدة للحزن أمر محتمل إذا انطبقت المعايير التالية كافة على الشخص: خسارة واحدة أو أكثر خلال 6 أشهر تقريب ا أحد الأعراض المذكورة أعلاه قد بدأ بعد الخسارة صعوبات هائلة في الأداء اليومي بسبب الأعراض )تتخطى ما هو متوقع ثقافيا(ً أو السعي للحصول على المساعدة بسبب الأعراض. » البحث عن أية حالات بدنية يمكنها أن تفّسر الأعراض وتدبيرها وفقا ً لذلك إن ُوجدت. » البحث عن أي اضطراب نفسي وعصبي واستخدام مواد إدمان آخر (بما في ذلك الاكتئاب) يتطرّق إليه هذا الدليل بإمكانه تفسير الأعراض، وتدبيره وفقا ًلذلك إن ُوجد. 91٤ قد تطول هذه الفترة أكثر من 6 أشهر في الثقافات التي تزيد فيها المدة المتوقعة للحداد/فقدان شخص عزيز عن 6 أشهر. خطة التدبير الأساسية 1. توفير الدعم النفسي الاجتماعي الأساسي » الاستماع جيدا.ً عدم الضغط على الشخص للتكلم. » سؤال الشخص عن حاجاته/حاجاتها ومخاوفه/مخاوفها. » مساعدة الشخص على تلبية حاجاته الأساسية والحصول على الخدمات واقامة الروابط مع الأسرة وأشكال الدعم الاجتماعي الأخرى. » حماية الشخص من أي أذى )إضافي(. » االتعامل مع الضغوطات النفسية الاجتماعية الحالية. » تعزيز الدعم الاجتماعي. » تعليم كيفية التعامل مع الضغط النفسي. » بعد التعرّض لخسارة كبيرة، تختلف ردود الفعل باختلاف الأشخاص فمنهم من يتأثر كثيرا ًعلى الصعيد العاطفي على عكس آخرين. » البكاء ليس تعبيرا ًعن الضعف. » الأشخاص الذين لا يبكون قد تعتريهم مشاعر أليمة عميقة إلا أنهم يعّبرون عنها بطرق مختلفة. » قد تظن أن الأسى والألم اللذين تشعر بهما لن يضمحلا أبدا،ً إلا أّن هذه المشاعر في معظم الحالات تتلاشى مع الوقت شيئا ًفشيئا.ً » في بعض الأحيان، قد يشعر الشخص بالتحّسن لفترة من الزمن ثم يذكّره أمر ما بالخسارة فيشعر بالسوء مجّددا.ً هذا أمر طبيعي. نكّرر بأن هذه التجارب تفقد من حّدتها وتواترها مع الوقت. » ما من طريقة صحيحة أو غير صحيحة للإحساس بالحزن، ففي بعض الأحيان قد تكون حزينا ًجدا ًوفي أوقات أخرى قد تتمّكن من التمتّع. لا تنتقد ذاتك لأجل ما تشعر به الآن. » سؤال الشخص عّما إذا حصلت مراسم/شعائر الحداد المناسبة أو تّم التخطيط لها. في حال النفي، مناقشة المعوقات وكيفية تخفيفها. » معرفة ما حصل للجثة. إذا كانت الجثة مفقودة، المساعدة على تعّقب أثرها أو التعرّف على البقايا. » إذا كان إيجاد الجثة أمرا ًمستحيلاً، مناقشة الطرق البديلة للاحتفاظ بالذكريات، كالنصب التذكارية. ۲. توفير الدعم النفسي الاجتماعي الإضافي كما هو موصوف في مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية): ۳. تثقيف الشخص بشأن ردود الفعل الشائعة الناجمة عن الخسارة، مثلاً: ٤. معالجة الحالات المرضّية المتزامنة ٦. إن كان ذلك ممكنا ًوملائما ًثقافيا،ً حّث الشخص على استئناف أنشطته العادية السابقة (كالذهاب إلى المدرسة أو العمل، في المنزل أو على المستوى الاجتماعي). ٧. بالتحديد لمعالجة مشاكل النوم، التبّول اللاإرادي، فرط التهوية، والأعراض الانشقاقية إثر خسارة مستجّدة، مراجعة الأجزاء ذات الصلة في الوحدة المتعلقة بالكرب الحاد (>> UCA). 5. مناقشة إجراءات الحداد* (gninruom) /التأقلم الملائمة ثقافيا ًودعمها »عدم وصف الأدوية لمعالجة أعراض الحزن. 02)>> IVW ,FTW ,OHW - 3102(.5 الأسلوب الموصوف هنا يُشار إليه غالبا ًبالإسعافات النفسية الأولية )AFP( عند تطبيقه فور وقوع حدث عصيب جدا ً » الإجابة على أسئلة الطفل بإعطاء شروحات واضحة وصريحة تتوافق مع مستوى نمّوه. عدم الكذب عندما يسألك الطفل عن الخسارة التي لحقت به )على سبيل المثال، أين والدتي؟(. فهذا سيربكه ويسيء إلى ثقته في مقّدم الرعاية الصحية. » البحث عن "التفكير السحري أو الخيالي" الشائع بين الأطفال الصغار وتصحيحه )على سبيل المثال، قد يعتقد الأطفال بأنهم مسؤولون عن الخسارة، قد يظنون مثلاً بأن الشخص العزيز على قلبهم قد مات لأنهم أساؤوا التصرف أو أثاروا غضبه(. » عند الحاجة، ربط الشخص بوكالات/شبكات الحماية الموثوقة. » من الممكن أن يكون الشخص قد أصيب باضطراب حزن طويل الأَمد إذا اتسمت أعراض فقدان شخص عزيز بانغماس عميق بالشخص المتوفي أو بشوق شديد إليه مصحوب بمشاعر أليمة مبرحة وبصعوبات هائلة في الأداء اليومي خلال 6 أشهر على الأقل6. ٨. إذا كان الشخص طفلاً صغيرا:ً ٩. بالنسبة إلى الأطفال والمراهقين والأشخاص شديدي التأثر الآخرين الذين فقدوا أهلاً لهم أو قائمين آخرين على العناية بهم، التعامل مع حاجتهم للحماية وضمان منحهم الرعاية الثابتة والداعمة، بما في ذلك الدعم الاجتماعي العاطفي. 01. في حال الاشتباه باضطراب حزن طويل الأَمد، استشارة طبيب مختص من أجل التوسع في التقييم والتدبير. 11. الطلب من الشخص العودة بعد أسبوعين إلى أربعة أسابيع إن لم تتحّسن الأعراض أو في أي وقت إذا ازدادت الأعراض سوءا.ً 126 قد تطول هذه الفترة أكثر من 6 أشهر في الثقافات التي تزيد فيها المدة المتوقعة للحداد/فقدان شخص عزيز عن 6 أشهر. الاضطراب الاكتئابي المعتدل إلى الحاد من الممكن أن يصاب البالغون والمراهقون والأطفال بالاضطراب الاكتئابي المعتدل إلى الحاد في غياب أية ضغوطات. ففي أي مجتمع نجد أشخاصا ً يعانون من اضطراب اكتئابي معتدل إلى حاد. إلا أّن الضغط النفسي والخسائر الكبيرة الناجمة عن حالات الطوارئ الإنسانية قد تولّد الحزن والخوف والذنب والعار واليأس، فترفع من خطر الإصابة باضطراب اكتئابي معتدل إلى حاد. لكن هذه المشاعر يمكنها أن تكون أيضا ًردود فعل طبيعية نتيجة المصاب الأليم المستجّد. لا يجب التفكير في معالجة الاضطراب الاكتئابي المعتدل إلى الحاد إلا إذا استمرّت أعراض الشخص بضعة أسابيع وسّببت له صعوبات هائلة في أداء الأنشطة اليومية. الشكاوى النموذجية للاضطراب الاكتئابي المعتدل إلى الحاد: تدني مستوى الطاقة، تعب، مشاكل في النوم أعراض بدنية عديدة مستمرة لا سبب واضح لها (مثل الآلام والأوجاع) حزن أو مزاج مكتئب مستمر، قلق قلة الاهتمام أو الاستمتاع بالأنشطة 22 التقييم السؤال التقييمي 1: هل يعاني الشخص من اضطراب اكتئابي معتدل إلى حاد؟ السؤال التقييمي ۲: هل من تفسيرات ممكنة أخرى لهذه الأعراض (غير الاضطراب الاكتئابي المعتدل إلى الحاد)؟ السؤال التقييمي 1: هل يعاني الشخص من اضطراب اكتئابي معتدل إلى حاد؟ » تقييم ما يلي 7: أ. لقد عانى الشخص مّما لا يقل عن واحد من أعراض الاضطراب الاكتئابي الرئيسية التالية خلال أسبوعين على الأقل: مزاج مكتئب مستمر – عند الأطفال والمراهقين: إما سهولة انفعال أو مزاج مكتئب قلة الاهتمام أو الاستمتاع بالأنشطة بدرجة ملحوظة، بما في ذلك الأنشطة التي كانت في السابق ممتعة – تتصف بتدني الرغبة الجنسية. ب. لقد عانى الشخص مّما لا يقل عن بضعة من الأعراض الإضافية التالية للاضطراب الاكتئابي بشكل ملحوظ (أو العديد من الأعراض المذكورة بدرجة أخف) خلال أسبوعين على الأقل: اضطراب النوم أو النوم أكثر من اللازم تغير هام في الشهية أو الوزن )زيادة أو نقصانا(ً أفكار بالذنب المفرط أو عدم الجدارة تعب أو فقدان الطاقة تدني القدرة على التركيز وعلى حصر الاهتمام بالمهام ترّدد هياج أو تململ بدني ملحوظ تكلّم أو تحرّك ببطء أكبر من المعتاد اليأس بشأن المستقبل أفكار أو أفعال انتحارية ج. يواجه الشخص صعوبات هائلة في الأداء اليومي على المستوى الشخصي والعائلي والاجتماعي والتربوي والمهني أو على مستويات مهمة أخرى. » إن توفرت النقاط أ ب ج جميعها خلال أسبوعين على الأقل، يحتمل أن يكون الشخص عندئذ مصابا ًباضطراب اكتئابي معتدل إلى حاد. قد يعاني الشخص من الأوهام* )snoisuled( أو الهلوسات* )snoitanicullah(. يجب تقّصيها. إن ثبت وجودها، يجب تكييف علاج الاضطراب الاكتئابي واستشارة أخصائي. في حال لم تتطابق أعراض الشخص مع معايير الاضطراب الاكتئابي المعتدل إلى الحاد، الانتقال إلى وحدة شكاوى الصحة النفسية الهامة الأخرى >> HTO لتقييم الشكوى المعروضة وتدبيرها. » استبعاد الحالات المرضية البدنية المتزامنة التي قد تشبه الاضطراب الاكتئابي. استبعاد فقر الدم، سوء التغذية، قصور الغدة الدرقية* )msidioryhtopyh(، السكتة الدماغية والآثار الجانبية للأدوية )مثل تقلب المزاج بسبب الاستيرويدات* )sdiorets(( ومعالجتها عند الاقتضاء. استبعاد حصول نوبة أو نوبات هوس سابقة. تقييم ما إذا ظهرت في فترة ماضية بضعة من الأعراض التالية بشكل متزامن: – تدّني الحاجة للنوم – المزاج المنتشي أو المبتهج أو المتهيّج – تطاير الأفكار، سهولة التشتّت – زيادة النشاط، الإحساس بزيادة الطاقة أو الثرثرة الشديدة – السلوك المندفع أو المتهور مثل الإفراط في المقامرة أو الإنفاق، اتخاذ القرارات الهامة من دون التخطيط الجدي لها – شعور غير واقعي بالعظمة. تقييم حجم الاختلال في الأداء الوظيفي للشخص أو حجم الخطر الذي ألحقته الأعراض بالشخص أو بأشخاص آخرين. على سبيل المثال: – هل شّكل نشاطك المفرط مشكلة لك أو لأسرتك؟ هل حاول أحدهم إدخالك إلى المستشفى أو احتجازك خلال ذلك الوقت بسبب سلوكك؟ يكون الشخص قد أصيب فعلاً بنوبة أو بنوبات هوس سابقة في حال تحقق الشرطين التاليين: – ظهرت بضعة من الأعراض الستة المذكورة أعلاه لمّدة تتعّدى الأسبوع. – سبّبت الأعراض صعوبات هائلة في الأداء اليومي للشخص أو شكلت خطرا ًعلى الشخص أو آخرين. في حال حصول نوبة هوس في وقت من الأوقات، يحتمل أن يشكل الاكتئاب عندئذ جزءا ًمن اضطراب آخر يُعرف بالاضطراب ثنائي القطب* )redrosid ralopib( وأن يستدعي معالجة مختلفة )>> مربع 2PED في نهاية هذه الوحدة(. 327 يتوافق هذا الوصف للاضطراب الاكتئابي المعتدل إلى الحاد مع المراجعة الحادية عشرة للتصنيف الدولي للأمراض 11-DCI. السؤال التقييمي ۳: هل يعاني الشخص من اضطراب نفسي وعصبي واستخدام مواد إدمان متزامن يستلزم المعالجة؟ » تقييم أفكار أو خطط الانتحار أو إيذاء الذات )>> IUS(. » تقييم التعاطي الضار للكحول أو مواد الإدمان )>> BUS(. » إذا كان الشخص يعاني من اضطراب نفسي وعصبي واستخدام مواد إدمان متزامن، معالجة هذا الاضطراب فضلاً عن الاضطرارب الاكتئابي المعتدل إلى الحاد في الوقت عينه. » استبعاد ردود الفعل الطبيعية نتيجة خسارة كبيرة (مثل فقدان شخص عزيز، نزوح) (>> IRG) من المرّجح أن تكون ردود الفعل هذه ردود فعل طبيعية ناجمة عن خسارة كبيرة في حال: – حصول تحّسن ملحوظ مع الوقت بغياب أي تدخل سريري؛ – عدم ظهور أي من الأعراض التالية: شعور بعدم الجدارة أفكار انتحارية تكلم أو تحرك ببطء أكبر من المعتاد أعراض ذهان )أوهام أو هلوسات(؛ – لم يكن هناك تاريخ سابق من الاضطراب الاكتئابي أو نوبات الهوس؛ – ولم تسّبب الأعراض صعوبات هائلة في الأداء اليومي. استثناء: اختلال الأداء الوظيفي يمكن أن يشكل جزءا ًمن الاستجابة الطبيعية لفقدان شخص عزيز إذا كان الأمر متعارفا ً عليه في ثقافة الشخص. استبعاد اضطراب حزن طويل الأمد: تتّسم أعراضه بانغماس عميق بالشخص المتوفي وبشوق شديد إليه مصحوب بمشاعر أليمة مبرحة وبصعوبات هائلة في الأداء اليومي خلال ستة أشهر على الأقل )ولمدة أطول بكثير مما هو متوقع في ثقافة الشخص(. في حال الاشتباه بهذا الاضطراب، استشارة أخصائي. 42 خطة التدبير الأساسية التدخلات النفسية الاجتماعية 1. توفير التثقيف النفسي » الرسائل الأساسية الموّجهة للشخص وللقائمين على العناية به: الاكتئاب مشكلة شائعة جدا ًيمكن أن تحدث لأي شخص. إن الإصابة بالاكتئاب لا تعني أّن الشخص ضعيف أو كسول. إن المواقف السلبية للآخرين )كقولهم "يجب أن تكون أقوى" و"تمالك نفسك"( ناجمة عن أّن الاكتئاب ليس حالة مرضيّة مرئية )على اختلاف الإصابة أو الكسر( وعن الأفكار الخاطئة بأّن الأشخاص يمكنهم السيطرة بسهولة على اكتئابهم بقوة إرادتهم. يميل الأشخاص المصابون بالاكتئاب إلى تكوين آراء سلبية غير واقعية عن أنفسهم وحياتهم ومستقبلهم. ربما يكون وضعهم الحالي صعبا جدا،ً إلا أّن الاكتئاب قد يمنحهم شعورا ًغير مّبرر باليأس وعدم الجدارة. من المرجح أن تتحسن هذه الأفكار بمجرد أن يتحسن الاكتئاب. على الرغم من صعوبة الأمر، يتوجب على الشخص محاولة القيام بأكبر عدد ممكن من الأمور التالية بحيث أنها تساعد جميعها على تحسين المزاج: – محاولة استئناف )أو مواصلة( الأنشطة التي كانت ممتعة في السابق. – محاولة الحفاظ على أوقات نوم واستيقاظ منتظمة. – محاولة ممارسة نشاط بدني بقدر الإمكان. – محاولة تناول الطعام بانتظام على الرغم من التغير في الشهية. – محاولة قضاء الوقت مع الأصدقاء الموثوقين والأسرة. – محاولة المشاركة في الأنشطة المجتمعية وغيرها من الأنشطة الاجتماعية، بقدر الإمكان. يجب أن يكون الشخص مدركا ًلأفكار إيذاء الذات أو الانتحار. وان أمكنه تمييزها، لا يجدر به تنفيذها إنما إبلاغ شخص موثوق والعودة لطلب المساعدة فورا.ً التعامل مع الضغوطات النفسية الاجتماعية الحالية. تعزيز الدعم الاجتماعي. – محاولة إعادة تنشيط الشبكات الاجتماعية السابقة للشخص. تحديد الأنشطة الاجتماعية السابقة التي يمكنها في حال استئنافها توفير الدعم النفسي الاجتماعي المباشر أو غير المباشر )مثل التجمعات العائلية، زيارة الجيران، الأنشطة المجتمعية(. تعليم كيفية التعامل مع الضغط النفسي. » الإرشاد بحل المشاكل* )gnillesnuoc gnivlos-melborp( » العلاج النفسي بين الأشخاص* )TPI-ypareht lanosrepretni( » العلاج السلوكي المعرفي* )TBC-ypareht laruoivaheb evitingoc( » التنشيط السلوكي* )noitavitca laruoivaheb( ۲. توفير الدعم النفسي الاجتماعي كما هو موصوف في مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية): ۳. في حال توفر المعالجين المدّربين الخاضعين للإشراف، النظر في حّث الأشخاص المصابين بالاكتئاب المعتدل إلى الحاد على استخدام أحد العلاجات النفسية القصيرة التالية كلما كانت متاحة: ثمّة أدلة متزيدة على أّن العلاجات النفسية القصيرة للاكتئاب يمكن أن يديرها عاملون مجتمعيون/غير متخّصصون مدربون خاضعون للإشراف. 52 التدخلات الدوائية 1. النظر في استخدام الأدوية المضادة للاكتئاب » للأطفال دون الثانية عشرة من العمر: عدم وصف الأدوية المضادة للاكتئاب » للمراهقين ما بين ۲1 – ٨1 عاما:ً عدم التفكير في وصف الأدوية المضادة للاكتئاب كخطوة علاج أُولى. توفير التدخلات النفسية الاجتماعية أولاً. » للبالغين: إذا كان الشخص مصابا ًبحالة مرضّية بدنية متزامنة تشبه الاضطراب الاكتئابي (>> السؤال التقييمي ۲)، معالجة هذه الحالة في البدء دوما.ً التفكير في وصف الأدوية المضادة للاكتئاب إذا لم يتحّسن الاضطراب الاكتئابي بعد معالجة الحالات المرضيّة البدنية المتزامنة. في حال الاشتباه بأن الأعراض مجرد ردود فعل طبيعية على خسارة كبيرة (>> السؤال التقييمي ۲)، عدم وصف الأدوية المضادة للاكتئاب. مناقشة الأمر مع الشخص والاتفاق معه على إمكانية وصف الأدوية المضادة للاكتئاب. شرح ما يلي: – إن الأدوية المضادة للاكتئاب لا تسبّب الإدمان. – من الضروري تناول الدواء كل يوم حسب الوصفة. – قد يشعر الشخص ببعض الآثار الجانبية (>> الجدول 1PED) خلال الأيام القليلة الأولى إلا أنّها تتلاشى عادة. – قد نحتاج عادة لبضعة أسابيع قبل ملاحظة أي تّحسن في المزاج أو الاهتمامات أو الطاقة. يجب الاستمرار عادة في تناول الأدوية المضادة للاكتئاب مدة 9 – ۲1 شهرا ًعلى الأقل بعد تحّسن حال الشخص. لا يجب إيقاف الدواء لمجرد أّن الشخص يشعر ببعض التحّسن )فهو ليس بمسّكن للصداع(. تثقيف الشخص بشأن المدة الزمنية الموصى بها لتناول الدواء. » اختيار مضاد اكتئاب وفقا ًلعمر الشخص، للحالات المرضيّة المتزامنة ولنمط الآثار الجانبية للدواء )>> الجدول 1PED(. » للمراهقين في عمر ۲5 سنة وما فوق: النظر في استخدام الفلوكستين )ولكن لا غيره من مضادات الاكتئاب المانعة لإعادة امتصاص السيروتونين الانتقائية )IRSS( أو مضادات الاكتئاب ثلاثية الحلقات )ACT(( فقط إذا استمرّت الأعراض أو ازدادت سوءا ًعلى الرغم من التدخلات النفسية الاجتماعية. » للنساء الحوامل أو المرضعات: إن أمكن، تجّنب مضادات الاكتئاب. النظر في استخدام أدنى جرعة فّعالة من مضادات الاكتئاب إذا لم تكن هناك استجابة للتدخلات النفسية الاجتماعية. في حال الإرضاع، تجّنب الفلوكستين. استشارة أخصائي إن توفر. للمسّنين: تجّنب الاميتريبتيلين إن أمكن. » للمصابين بأمراض القلب والأوعية الدموية: عدم وصف الاميتريبتيلين. » للبالغين الذين لديهم أفكار أو خطط انتحارية: الفلوكستين هو الخيار الأول. إذا كان هناك خطر وشيك بإيذاء الذات أو الانتحار (>> IUS)، تزويد الشخص بكمية محدودة من مضادات الاكتئاب فحسب )على سبيل المثال، كمية تكفي أسبوعا(ً. الطلب من القائمين على العناية بالشخص الاحتفاظ بالأدوية ومراقبتها، والمتابعة على نحو متكرر لتفادي الجرعة الزائدة. ۲. في حال الاتفاق على وصف الأدوية المضادة للاكتئاب، اختيار مضاد اكتئاب مناسب (>> الجدول 1PED) 62 الجدول 1PED: مضادات الاكتئاب الفلوكستين )IRSSج(الاميتريبتيلينأ )ACT ب( 1 ملغم مرة في اليوم. زيادتها الى∙ ۲ ملغم 5۲ - 05 ملغم قبل النومالجرعة الابتدائية للبالغين بعد أسبوع. لا تنطبق )عدم وصف مضادات الاكتئاب الجرعة الابتدائية للمراهقين ثلاثية الحلقات للمراهقين( 01 ملغم مرة في اليوم 01 ملغم مرة في اليوم5۲ ملغم قبل النومالجرعة الابتدائية للمسّنين والمريضين طبياً في حال عدم الاستجابة بعد 6 أسابيع، زيادة بنسبة 5۲ - 05 ملغم في الأسبوعزيادة الجرعة للبالغين زيادتها إلى 0٤ ملغم مرة في اليوم 001 - 051 ملغم )الجرعة القصوى 003 الجرعة الفعالة المعيارية للبالغين ملغم(د 02 - 0٤ ملغم )الجرعة القصوى 08 ملغم( الجرعة الفعالة المعيارية للمراهقين والمسّنين والمريضين طبياً 05 - 57 ملغم )الجرعة القصوى 001 ملغم(. عدم وصفها للمراهقين 02 ملغم )الجرعة القصوى 0٤ ملغم( تعّذر الجلوس* )aisihtaka( مطولاً عدم انتظام ضربات القلبالآثار الجانبية الخطيرة والنادرة حالات نزيف شاذة لدى الأشخاص الذين يستخدمون الأسبرين وغيره من مضادات الالتهاب اللاستيرويدية* )diorets-non sDIASN sgurd yrotammaflni-itna( أفكار إيذاء الذات )بشكل خاص لدى المراهقين والبالغين الشباب( انخفاض ضغط الدم أثناء الوقوف )خطر الآثار الجانبية الشائعة السقوط(، جفاف الفم، إمساك، صعوبة في التبّول، دوخة، عدم وضوح الرؤية وشعور بالتخدير صداع، تململ، حّدة طباع، اضطرابات هضمية، خلل جنسي قابل للعكس إن أُصيب الشخص بنوبة هوس، إيقاف المحاذير الدواء فوراً إن أُصيب الشخص بنوبة هوس، إيقاف الدواء فوراً أ متوفر في المجموعة الصحية المشتركة بين الوكالات لحالات الطوارئ )منظمة الصحة العالمية، 1102( ب تشير ACT إلى مضادات الاكتئاب ثلاثية الحلقات ج تشير IRSS إلى مضادات الاكتئاب المانعة لإعادة امتصاص السيروتونين الانتقائية 72د الجرعة الفعالة الدنيا عند البالغين: 57 ملغم )يمكن ملاحظة شعور بالتخدير بجرعات أصغر(. ۳. المتابعة » توفير المتابعة المنتظمة. ترتيب جلسات متابعة منتظمة وإجراؤها وفقا ًلمبادئ التدبير (>> المبادئ العامة للرعاية). تحديد الموعد الثاني خلال أسبوع والمواعيد اللاحقة وفقا ًلتطور الاضطراب. » مراقبة الاستجابة لمضادات الاكتئاب. إن مضادات الاكتئاب تحتاج لبضعة أسابيع قبل إعطاء مفعول. مراقبة الاستجابة بعناية قبل زيادة الجرعة. إذا ظهرت أعراض نوبة هوس (>> السؤال التقييمي ۲)، إيقاف الدواء فورا ًوالانتقال إلى وحدة الذهان >> YSP لمعالجة نوبة الهوس. النظر في تقليل جرعة الدواء 9 إلى ۲1 شهرا ًبعد زوال الأعراض. تقليص الجرعة تدريجيا ًعلى امتداد أربعة أسابيع على الأقل. المربع 2PED : المعالجة الطبية لنوبة اكتئاب حالية لشخص مصاب باضطراب ثنائي القطب للأشخاص المصابين باضطراب ثنائي القطب، عدم وصف مضادات الاكتئاب وحدها من دون مثبت مزاج، لأن مضادات الاكتئاب قد تؤدي إلى نوبة هوس. إذا كان للشخص تاريخ من نوبات الهوس: » استشارة أخصائي. » إن لم يتوفر أخصائي فورا،ً وصف مضاد اكتئاب مع مثبت مزاج مثل الكاربامازيبين أو الفالبروات (>> الجدول 2PED). البدء بجرعة خفيفة من الدواء. زيادة الجرعة ببطء خلال الأسابيع اللاحقة. – إن أمكن، تفادي الكاربامازيبين والفالبروات للنساء الحوامل أو النساء اللواتي يخططن للحمل، نظرا ًللأذى الذي يحتمل أن يسبّبه الدواء للجنين. إن قرار البدء بمثبتات المزاج لدى المرأة الحامل يجب اتخاذه بالتشاور مع المرأة. يجب أن تؤخذ بعين الاعتبار حّدة نوبات الاكتئاب والهوس وتواترها. استشارة أخصائي بشأن العلاج القائم لاضطراب ثنائي القطب. » إعلام الشخص والقائمين على العناية به بإيقاف مضاد الاكتئاب فورا ًوبالعودة للحصول على المساعدة في حال ظهور أعراض نوبة هوس. الجدول 2PED : مثبتات المزاج في حال الاضطراب ثنائي القطب فالبرواتكاربامازيبين 00٤ ملغم/اليوم002 ملغم/اليومالجرعة الابتدائية 00٤ - 006 ملغم/اليوم )الجرعة القصوى 00٤1 ملغم/الجرعة الفعالة المعيارية اليوم( 0001 - 0002 ملغم/اليوم )الجرعة القصوى 0052 ملغم/اليوم( مرتين في اليوم، عن طريق الفممرتين في اليوم، عن طريق الفمجدول الجرعات الآثار الجانبية النادرة والخطيرة طفح جلدي حاد )متلازمة ستيفنز جونسون* )emordnys nosnhoJ-snevetS(، تقشر الأنسجة المتموتة البشروية التسممي* )lamredipe cixot sisylorcen( كبت نخاع العظم* )noisserped worram enob( نعاس تشّوش نعاسالآثار الجانبية الشائعة صعوبة في المشي غثيان خمول شعور بالتخدير ارتعاش غثيان، إسهال زيادة في الوزن فقدان شعر عابر )ينمو عادة في غضون 6 أشهر( 82 اختلال وظائف الكبد اضطراب الكرب ما بعد الصدمة كما أوضحنا في الوحدة المتعلقة بالكرب الحاد (UCA)، من الشائع أن يُصاب البالغون والمراهقون والأطفال بمجموعة واسعة من ردود الفعل أو الأعراض النفسية بعد التعرّض لضغط نفسي شديد خلال حالات الطوارئ الإنسانية. بالنسبة إلى معظم الأشخاص، تكون هذه الأعراض مؤقتة. في حال استمرار مجموعة مميزة ومعّينة من الأعراض (عيش التجربة من جديد، تجّنب، إحساس متصاعد بالخطر الراهن( أكثر من شهر بعد وقوع حدث قادر على التسّبب بصدمة* (tneve citamuart yllaitnetop)، من المرجح أن تكون الأعراض قد تطوّرت إلى اضطراب الكرب ما بعد الصدمة (DSTP). على الرغم من اسمه، من غير الضروري أن يكون اضطراب الكرب ما بعد الصدمة الحالة المرضّية الوحيدة أو الرئيسية الناتجة عن التعرّض لأحداث قادرة على التسّبب بصدمة. فمثل هذه الأحداث يمكنها التسّبب بالعديد من الاضطرابات النفسية والعصبية واستخدام مواد الإدمان الأخرى التي تّم وصفها في هذا الدليل. الشكاوى النموذجية المتعلّقة باضطراب الكرب ما بعد الصدمة قد يصعب تمييز الأشخاص المصابين باضطراب الكرب ما بعد الصدمة من أولئك الذين يعانون من مشاكل أخرى إذ قد تظهر عليهم في البدء أعراض غير مميزة مثل: » مشاكل في النوم )كنقص في النوم( » سهولة انفعال، مزاج قلق أو مكتئب مستمر » أعراض بدنية عديدة متواصلة لا سبب بدني واضح لها )مثل الصداع، خفقان القلب بشّدة(. غير أنه في أثناء الاستجواب، قد يتّضح أنهم يعانون من الأعراض المميزة لاضطراب الكرب ما بعد الصدمة. 92 التقييم السؤال التقييمي 1: هل تعرّض الشخص لحدث قادر على التسّبب بصدمة منذ أكثر من شهر؟ السؤال التقييمي ۲: إذا تعرّض الشخص لحدث قادر على التسّبب بصدمة منذ أكثر من شهر، فهل أُصيب بنتيجته باضطراب الكرب ما بعد الصدمة٨؟ السؤال التقييمي ۳: هل يعاني الشخص من حالة مرضّية متزامنة؟ » سؤال الشخص عّما إذا تعرّض لحدث قادر على التسّبب بصدمة. وهو كل حدث مرّوع أو مهّدد للحياة كعنف جسدي أو جنسي )بما في ذلك العنف الأسري(، مشاهدة أعمال وحشية، تدمير منزل الشخص، إصابات أو حوادث كبرى. طرح الأسئلة التالية: كيف تأثرت بالنزاع/الكارثة؟ هل كانت حياتك في خطر؟ هل مررت داخل المنزل أو المجتمع بتجربة مخيفة جدا ًأو مرّوعة أو جعلتك تشعر بضيق شديد؟ » إذا تعرّض الشخص فعلاً لحدث قادر على التسبّب بصدمة، السؤال عن زمن حدوثه. » تقييم الآتي: أعراض عيش التجربة من جديد. إنها استعادة متكّررة وغير مرغوب بها للحدث كما لو أنه يحصل الآن وهنا )على سبيل المثال، في الكوابيس، أو الارتجاع* )kcabhsafl(، أو الذكريات الاقتحامية* )seiromem evisurtni( المصحوبة بخوف شديد أو رعب(. – عند الأطفال، هذا يشمل لعب أو رسم الأحداث بشكل متكّرر، أما الأطفال الأصغر سنا ًفقد تزعجهم الكوابيس الخالية من مضمون واضح. أعراض التجّنب. وتشمل التجّنب المتعّمد للأفكار أو الذكريات أو الأنشطة أو الأوضاع التي تذكر الشخص بالحدث )كأن يتجّنب التكلم بالمسائل التي تذكره بالحدث أو يتجّنب العودة إلى الأماكن التي حصل فيها الحدث(. الأعراض المتعلقة بالإحساس المتصاعد بالخطر الراهن )تدعى غالبا ً "أعراض فرط التيقظ"(. وهي تشمل التخوف الشديد والتيقظ للخطر أو إصدار ردود فعل قوية على الأصوات الصاخبة أو الحركات غير المتوقعة )كأن يكون الشخص سريع الاهتياج أو الانفعال(. اصعوبات هائلة في الأداء اليومي. » إن توفرت النقاط المذكورة أعلاه كافة بعد شهر من الحدث تقريبا،ً من المرّجح أن تكون الأعراض قد تطورت إلى اضطراب الكرب ما بعد الصدمة. » تقييم وتدبير أية حالات مرضّية بدنية متزامنة يمكنها أن تفّسر الأعراض. » تقييم وتدبير كافة الاضطرابات النفسية والعصبية واستخدام مواد الإدمان الأخرى التي يتطرّق إليها هذا الدليل. 8 يتوافق وصف اضطراب الكرب ما بعد الصدمة مع المراجعة الحادية عشرة للتصنيف الدولي للأمراض 11-DCI، مع اختلاف واحد: إن المراجعة الحادية عشرة 11-DCI تتيح تصنيف اضطراب الكرب ما بعد الصدمة في ظرف شهر )مثلاً بضعة أسابيع( بعد الحدث. وهي لا تشمل أعراضا ًغير مميزة لاضطراب الكرب ما بعد الصدمة مثل الانفعال 03والشعور بالتخدير. خطة التدبير الأساسية 1. التثقيف بشأن اضطراب الكرب ما بعد الصدمة » شرح ما يلي: إن العديد من الأشخاص يتعافون مع الوقت من اضطراب الكرب ما بعد الصدمة من دون علاج في حين أن البعض الآخر يتطلب علاجا.ً إن الأشخاص المصابين باضطراب الكرب ما بعد الصدمة يستعيدون بشكل متكرر وغير مرغوب به ذكريات الحدث الصادم. وعند حصول ذلك، تغمرهم مشاعر خوف ورعب مماثلة لتلك التي شعروا بها عند وقوع الحدث فعلاً. كما قد تزعجهم الكوابيس. إن الأشخاص المصابين باضطراب الكرب ما بعد الصدمة كثيرا ًما يشعرون بأن الخطر ما زال يحدق بهم وبالتالي يكونون شديدي التوتر. هم يجفلون بسهولة )سريعو الاهتياج( أو يبقون متيقظين للخطر. إن الأشخاص المصابين باضطراب الكرب ما بعد الصدمة يحاولون تجّنب كل ما يذكرهم بالحدث مما يسبّب لهم المشاكل في حياتهم. )حيثما ينطبق(، إن الأشخاص المصابين باضطراب الكرب ما بعد الصدمة يعانون أحيانا من المشاكل الصحية النفسية والبدنية الأخرى مثل الآلام والأوجاع البدنية، تدني الطاقة، التعب، الانفعالية والمزاج المكتئب. » تقديم الُنصح للأشخاص: مواصلة حياتهم الروتينية اليومية العادية بقدر الإمكان. التحّدث مع أشخاص موثوقين عّما أصابهم وعن مشاعرهم، إنما فقط حينما يكون الشخص مستعّدا ًلذلك. القيام بأنشطة تساعد على الاسترخاء بهدف تقليص القلق والتوتر. تجّنب الكحول أو مواد الإدمان بهدف التصّدي لأعراض اضطراب الكرب ما بعد الصدمة. » التعامل مع الضغوطات النفسية الاجتماعية الحالية. عندما يكون الشخص ضحية انتهاكات صارخة لحقوق الإنسان، التباحث معه بشأن إمكانية الإحالة إلى هيئة حماية موثوقة أو وكالة دفاع عن حقوق الإنسان. » تعزيز الدعم الاجتماعي » تعليم كيفية التعامل مع الضغط النفسي. » العلاج السلوكي المعرفي المركز على الصدمة* )laruoivaheb evitingoc sucof amuart a htiw ypareht( » إزالة حساسية حركة العين واعادة المعالجة * )tnemevom eye RDME-gnissecorper dna noitazitisnesed » مراجعة الوحدة المتعلقة بالاكتئاب المعتدل إلى الحاد للحصول على توجيهات مفّصلة حول وصف مضادات الاكتئاب )>> PED(. » عدم وصف مضادات الاكتئاب لمعالجة اضطراب الكرب ما بعد الصدمة عند الأطفال والمراهقين. » ترتيب جلسات متابعة منتظمة وإجراؤها وفقا ًلمبادئ التدبير (>> المبادئ العامة للرعاية). » تحديد الموعد الثاني بعد أسبوعين إلى أربعة أسابيع والمواعيد اللاحقة وفقا لتطّور الاضطراب. ۲. توفير الدعم النفسي الاجتماعي كما هو موصوف في مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية) ۳. في حال توفر المعالجين المدّربين الخاضعين للإشراف، النظر في الإحالة إلى: ٤. عند البالغين، النظر في استخدام مضادات الاكتئاب (مضادات الاكتئاب المانعة لإعادة امتصاص السيروتونين الانتقائية أو مضادات الاكتئاب ثلاثية الحلقات) عند فشل أو عدم توفر العلاج السلوكي المعرفي، إزالة حساسية حركة العين واعادة المعالجة أو التعامل مع الضغط النفسي 5. المتابعة 13 الذهان إن البالغين والمراهقين المصابين بالذهان يعتقدون اعتقادا ًراسخا ًأو يشعرون بأمور غير حقيقية، وتعتبر عموما ًأفكارهم وتجاربهم غير طبيعية من قبل مجتمعاتهم. إن الأشخاص المصابين بالذهان غالبا ًما لا يدركون أنهم يعانون من اضطراب نفسي وهم في كثير من الأحيان غير قادرين على التصرّف بشكل طبيعي على مستويات كثيرة. إن حالات الطوارئ الإنسانية قد تولّد الضغط النفسي والخوف الشديدين وتتسّبب في انهيار الدعم الاجتماعي واختلال خدمات الرعاية الصحية وامدادات الأدوية، وقد تؤدي هذه التغييرات إلى الذهان الحاد أو تزيد أعراض الذهان القائمة سوءا.ً في ظروف الطوارئ، يصبح الأشخاص المصابون بالذهان أكثر عرضة لمختلف أنواع انتهاكات حقوق الانسان مثل الإهمال، والهجر، والتشرد، والإساءة والوصمة الاجتماعية. الشكاوى النموذجية للذهان السلوك غير الطبيعي (كالمظهر الغريب، إهمال النفس، الكلام غير المترابط، التجوال من دون هدف، التمتمة أو الضحك لوحده) المعتقدات الغريبة سماع أصوات أو رؤية أشياء غير موجودة الشك القوي عدم الرغبة في البقاء برفقة أشخاص آخرين أو في التحدث إليهم، الافتقار إلى الدافع للقيام بالأعمال والمهام الرتيبة اليومية. 23 التقييم السؤال التقييمي 1: هل يعاني الشخص من الذهان؟ السؤال التقييمي ۲: هل من أسباب بدنية حادة للأعراض الذهانية يمكن معالجتها؟ السؤال التقييمي ۳: أهذه نوبة هوس؟ » على الرغم من أن الأشخاص المصابين بالذهان لديهم أفكار أو معتقدات أو أحاديث غير طبيعية، إلا أن هذا لا يعني أن كل ما يقولونه خطأ أو من نسج الخيال. إن الاستماع الجيد هو الأساس في تقييم الذهان. وقد لا تكفي زيارة واحدة لإجراء تقييم شامل. في كثير من الأحيان، يشكل القائمون على العناية بالشخص مصدرا ًللمعلومات المفيدة. » تقييم ما يلي: الأوهام* (snoisuled) )معتقدات أو شكوك خاطئة راسخة يتمّسك بها الشخص بقوة على الرغم من وجود إثبات بالعكس( – نصيحة: التدقيق أكثر بسؤال الشخص عن معنى كلامه والاستماع جيدا.ً الهلوسات* (snoitanicullah) )سماع أو رؤية أو الإحساس بأشياء غير موجودة( – هل تسمع أو ترى أشياء لا يسمعها أو يراها الأشخاص الآخرون؟ الأفكار غير المنتظمة التي تنتقل من موضوع لآخر من دون أي ترابط منطقي؛ الكلام الذي تصعب متابعته وفهمه التجارب الغريبة كاعتقاد الشخص بأن الآخرين يدخلون الأفكار في عقله أو بأن الآخرين يخرجون الأفكار من عقله أو بأن أفكاره تبث للآخرين. السلوك غير الطبيعي كالنشاط الغريب والعجيب والانفعالي والذي لا هدف منه أو إبقاء الجسد في وضعية غي طبيعية أو عدم التحرك بتاتا.ً الأعراض المزمنة التي تّتسم بانعدام الأداء الطبيعي، بما في ذلك: – فقدان الطاقة أو الدافع للقيام بالأعمال والمهام الرتيبة اليومية. – اللامبالاة أو الانسحاب الاجتماعي – قلة الاهتمام بالنفس أو الإهمال – غياب القدرة التعبيرية والتجربة الانفعالية. » الإصابة بالذهان أمر محتمل بوجود أعراض متعددة. التقييم دائما لمعرفة ما إذا كان هناك خطر وشيك بالانتحار )>> IUS( والأذى للآخرين وللنفس. » استبعاد الهذيان* )muiriled( من الأسباب البدنية الحادة كالرضوض في الرأس، العدوى )على سبيل المثال، الملاريا الدماغية، الإنتان* )sispes( أو الإنتان البولي* sispesoru(، الجفاف والاضطاربات الاستقلابية )على سبيل المثال، نقص جلوكوز الدم* )aimeacylgopyh(، نقص الصوديوم* )aimeartanopyh((. » استبعاد الآثار الجانبية للدواء )كتلك الناجمة عن بعض الأدوية المضادة للملاريا(. » استبعاد التسّمم بالكحول أو مواد الإدمان/الانقطاع عنها (>> BUS). – السؤال عن تعاطي الكحول أو استخدام المسكنات أو غيرها من مواد الإدمان. – اشتمام رائحة الكحول. » استبعاد الهوس. التقييم لمعرفة ما إذا توفرت الأعراض التالية: – تدّني الحاجة للنوم – المزاج المنتشي أو المبتهج أو المتهيّج – الأفكار المتسارعة، سهولة التشتّت – زيادة النشاط، الإحساس بزيادة الطاقة أو الثرثرة الشديدة – السلوك المندفع أو المتهور مثل الإفراط في المقامرة أو الإنفاق، اتخاذ القرارات الهامة من دون التخطيط الجّدي لها – شعور غير واقعي بالعظمة. » الإصابة بنوبة هوس أمر محتمل مع استمرار العديد من هذه الأعراض لأكثر من أسبوع، وإما أن تسبّب هذه الأعراض صعوبات هائلة في الأداء اليومي للشخص أو أن يتعذر الاهتمام بالشخص في المنزل بشكل آمن. 33 أ. التدخلات الدوائية 1. للذهان غير الناتج عن أسباب بدنية حادة » البدء بوصف مضاد ذهان عن طريق الفم. التفكير في العلاج بالحقن العضلي فقط حينما يتعذر العلاج عن طريق الفم. التحّقق مّما إذا سبق للشخص استخدام مضاد ذهان ساعده في السيطرة على الأعراض. في حال الإيجاب، وصف الدواء نفسه مجّددا ًبالجرعة ذاتها. إذا كان الدواء غير متوفر، يجب وصف دواء جديد. إن مساهمة القائم على العناية بالشخص أو مقّدم الرعاية الصحية في الاحتفاظ بالدواء وإعطائه للشخص أمر أساسي في بداية العلاج لضمان الالتزام الآمن به. وصف مضاد ذهان واحد في آن واحد )مثل الهالوبيريدول >> الجدول 1YSP( البدء بالجرعة العلاجية الأصغر وزيادتها ببطء للحصول على المفعول المرغوب به بالحد الأدنى من الجرعة الفعالة. تجربة الدواء لمدة زمنية كافية بالجرعة الفعالة النموذجية قبل التفكير بأنه غير فعال )لما لا يقل عن ٤ - 6 أسابيع )>> الجدول 1YSP(. – وصف الحد الأدنى من الجرعة الفعالة عن طريق الفم للنساء اللواتي يخططن للحمل، للنساء الحوامل أو المرضعات. إن لم ينجح مضاد الذهان وحده في السيطرة على الاهتياج بشكل مناسب، وصف جرعة من البنزوديازيبين )مثل الديازيبام، جرعة قصوى 5 ملغم عن طريق الفم( واستشارة أخصائي فورا.ً السيطرة على الآثار الجانبية. – في حال حصول آثار جانبية خارج الهرمية* )ladimarypartxe stceffe edis( حادة مهّمة مثل الباركنسونية )توليفة من الرعاش* )romert( والتيبّس العضلي وانخفاض حركة البدن( أو تعذر الجلوس* )aisihtaka( )عدم القدرة على الجلوس من دون حركة(: تقليص جرعة مضاد الذهان. إذا استمرت الآثار الجانبية خارج الهرمية على الرغم من تقليص الجرعة، النظر في استخدام الأدوية المضادة للكولينيات لأجل قصير )مثل البيبيريدين لمدة أربعة إلى ثمانية أسابيع( )>> الجدول 2YSP(. – في حال حصول ديستونيا/خلل توتر حاد )تشنج عضلي حاد، بشكل خاص في العنق أو اللسان أو الفك(: إيقاف مضاد الذهان بشكل مؤقت وإعطاء الأدوية المضادة للكولينيات )مثل البيبيريدين >> الجدول 2YSP(. في حال عدم توفرها، يمكن وصف الديازيبام لإثارة الاسترخاء العضلي. إن أمكن، استشارة أخصائي بشأن مدة العلاج ووقت إيقاف مضادات الذهان. – بشكل عام، مواصلة مضاد الذهان لمدة ۲1 شهرا ًعلى الأقل بعد زوال الأعراض. – في حال إيقاف الدواء، تخفيض الجرعة تدريجيا على امتداد بضعة أشهر. – عدم إيقاف الدواء بشكل مفاجئ. » معالجة السبب الحاد لمعالجة الانقطاع عن الكحول، راجع المربع 1 في الوحدة المتعلقة بالتعاطي الضار للكحول ومواد الإدمان. إن لم يكن الانقطاع عن الكحول هو السبب البدني الحاد، وصف مضاد للذهان عن طريق الفم حسب الحاجة )مثل الهالوبيريدول، في البدء جرعة 5،0 ملغم ثم زيادتها الى 2،0 - 5 ملغم ثلاث مرات في اليوم(. وصف مضاد ذهان فقط عند الحاجة للسيطرة على الاهتياج أو الأعراض الذهانية أو العدائية. إيقاف الدواء فور زوال هذه الأعراض. عدم التفكير في العلاج بالحقن العضلي إلا إذا تعّذر العلاج عن طريق الفم. » البدء بوصف مضاد ذهان عن طريق الفم (>> الفقرة 1 أعلاه تحت التدخلات الدوائية). » إذا كان الشخص مصابا ًبحالة من الاهتياج الشديد على الرغم من العلاج بمضاد ذهان، التفكير في إضافة جرعة من البنزوديازيبين )كالديازيبام، جرعة قصوى 5 ملغم عن طريق الفم( واستشارة أخصائي على الفور. » نوبة الهوس هي جزء من الاضطراب ثنائي القطب* )ralopib redrosid(. بعد السيطرة على الهوس الحاد، يجب تقييم ما إذا كان الشخص مصابا ًبالاضطراب ثنائي القطب ومعالجته بمثبت مزاج مثل الفالبروات أو الكاربامازيبين. استشارة أخصائي لتدبير الحالة و/أو اتباع التعليمات بشأن الاضطراب ثنائي القطب في الدليل الكامل لتدخلات برنامج رأب الفجوة في الصحة النفسية. ۲. للأعراض الذهانية الناتجة عن أسباب بدنية حادة (كالانقطاع عن الكحول أو الهذيان) ۳. لنوبة هوس خطة التدبير الأساسية 43 الجدول 1YSP: الأدوية المضادة للذهان ريسبريدونكلوربرومازينهالوبيريدولأالدواء 2 ملغم/اليوم05 - 57 ملغم/اليوم۲،5 ملغم/اليومالجرعة الابتدائية ٤ - 01 ملغم )الجرعة القصوى الجرعة الفعالة النموذجية 02 ملغم( 57 - 003 ملغم/اليومب )الجرعة القصوى 0001 ملغم( ٤ - 6 ملغم/اليوم )الجرعة القصوى 01 ملغم( عن طريق الفمعن طريق الفمعن طريق الفم/الحقن العضليطريقة إعطاء الدواء الآثار الجانبية المهمة: الآثار الجانبية خارج الهرمية* (stceffe edis ladimarypartxe) +++++ الشعور بالتخّدر (لاسّيما لدى المسّنين) +++++ ++التردد البولي انخفاض ضغط الدم عند الوقوف* (noisnetopyh citatsohtro) +++++ المتلازمة الخبيثة للدواء المضاد للذهان* (emordnys tnangilam citpeloruen) نادرةجنادرةجنادرةج الجدول 2YSP: الأدوية المضادة للكولينيات تريهكسفينيديلبيبيريدينأالدواء 1 ملغم/اليوم1 ملغم مرتين في اليومالجرعة الابتدائية 3 - 6 ملغم/اليوم )الجرعة القصوى 21 الجرعة الفعالة النموذجية ملغم( 5 - 51 ملغم/اليوم )الجرعة القصوى 02 ملغم( عن طريق الفمعن طريق الفمطريقة إعطاء الدواء الآثار الجانبية المهمة: التشوش، اضطراب الذاكرة (لاسّيما لدى المسّنين) ++++++ ++الشعور بالتخدر (لاسّيما لدى المسّنين) ++++التردد البولي أ متوفر في المجموعة الصحية المشتركة بين الوكالات لحالات الطوارئ )منظمة الصّحة العالمية، 1102( ب يمكن الوصول إلى غرام واحد في الحالات الحادة. ج إيقاف مضاد الذهان فورا ًفي حال الاشتباه بهذه المتلازمة والحفاظ على برودة الشخص وتزويده بالسوائل الكافية. 53أ متوفر في المجموعة الصحية المشتركة بين الوكالات لحالات الطوارئ )منظمة الصّحة العالمية، 1102( لكافة الحالات: 1. توفير التثقيف النفسي الرسائل الأساسية الموّجهة إلى الشخص والقائم أو القائمين على العناية به: » يمكن معالجة الذهان وبإمكان الشخص الشفاء منه. » إن الضغط النفسي يزيد الأعراض الذهانية سوءا.ً » محاولة مواصلة الأنشطة الاجتماعية والتعليمية والمهنية المنتظمة بقدر الإمكان، على الرغم من صعوبة الأمر في مواقع الطوارئ. » عدم استهلاك الكحول أو القنب أو الأدوية الأخرى غير الموصوفة، فقد تزيد أعراض الذهان سوءا.ً » الأشخاص المصابون بالذهان بحاجة لتناول الأدوية الموصوفة لهم ومتابعة حالتهم بشكل منتظم. » تحديد ما إذا كانت الأعراض الذهانية تعود أو تزداد سوءا.ً يجب عندها زيارة العيادة مجددا ًفلعله يتوجب تعديل العلاج وفقا ًلذلك. الرسائل الموّجهة إلى القائم أو القائمين على العناية بالشخص: » عدم محاولة إقناع الشخص بأن معتقداته/معتقداتها أو تجاربه/ تجاربها خاطئة أو غير حقيقية. » محاولة البقاء على الحياد واظهار الدعم حتى عندما يبدي الشخص سلوكا ًغريبا ًأو عدائيا.ً » تجّنب الجدال مع الشخص أو التعامل معه بعدائية. » محاولة منح الشخص حرية التحرك. تجّنب تقييد الشخص مع ضمان أمنه الأساسي وأمن الآخرين. » الذهان ليس ناتجا ًعن السحر أو الجن. » عدم لوم الشخص أو أفراد آخرين من أسرته أو اتهامهم بأنهم السبب في إصابته بالذهان. » إذا كان هذا الشخص امرأة قد أنجبت مؤخرا،ً عدم تركها وحدها مع الطفل وذلك من أجل ضمان سلامته. ب. التدخلات النفسية الاجتماعية » التحّدث مع قادة المجتمع لزيادة تقبّل المجتمع للشخص والتعامل معه برحابة صدر. » تسهيل إشراك الشخص في الأنشطة المجتمعية الاقتصادية والاجتماعية. » التواصل مع الموارد المجتمعية مثل العاملين الصحيين المحليين، العاملين في مجال خدمات الحماية، الأخصائيين الاجتماعيين، والعاملين في مجال خدمات الإعاقة. طلب مساعدتهم من أجل مساندة الشخص في استئناف الأنشطة الاجتماعية والتعليمية والمهنية المناسبة. ج. المتابعة » ترتيب جلسات متابعة منتظمة واجراؤها وفقا لمبادئ التدبير )>> المبادئ العامة للرعاية). » تحديد الموعد الثاني بعد أسبوع والمواعيد اللاحقة وفقا ًلتطّور الاضطراب. » مواصلة العلاج بمضاد الذهان مدة 21 شهرا ًعلى الأقل بعد زوال الأعراض بالكامل. إن أمكن، استشارة أخصائي بشأن قرار متابعة الدواء أو إيقافه. ۲. تيسير إعادة التأهيل في المجتمع ۳. توفير الرعاية للقائمين على العناية بالشخص وفقا ًلمبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية) 63 الصرع/النوبات الصرع هو من أكثر الاضطرابات النفسية والعصبية واستخدام مواد الإدمان التي يتّم علاجها في مواقع الطوارئ الإنسانية في البلدان المنخفضة والمتوسطة الدخل. يصيب الصرع كافة الفئات العمرية بما في ذلك الأطفال الصغار. الصرع حالة عصبيّة مزمنة تتّسم بنوبات متكررة لا محّفز لها، ناجمة عن نشاط كهربائي غير طبيعي في الدماغ. والصرع أنواع عديدة تغطي منها هذه الوحدة النوع الأكثر شيوعا ًفقط، ألا وهو الصرع الاختلاجي. يتميز الصرع الاختلاجي بنوبات تسبّب تقلصا ًعضليا ًغير إرادي مفاجئا ًيتناوب مع استرخاء العضلات، مما يؤدي إلى اهتزاز البدن والأطراف أو تصلّبها. ترتبط النوبات في كثير من الأحيان باختلال الوعي. إن الشخص المصاب بتشّنجات معرّض للسقوط والإصابة برضوض. خلال الطوارئ الإنسانية، غالبا ما تختل الإمدادات بالأدوية المضادة للاختلاج. وفي غياب مستمر للوصول إلى هذه الأدوية، يتعرّض الأشخاص المصابون بالصرع لنوبات جديدة قد تشكل خطرا ًعلى حياتهم. الشكاوى النموذجية للصرع الاختلاجي تاريخ من النوبات أو الحركات التشّنجية. مراجعة المربع 2 IPE في الصفحة 0٤ المتعلق بتقييم وعلاج شخص مصاب بتشّنجات أو فاقد للوعي بعد تعرضه لنوبة* (eruzies). 73 التقييم السؤال التقييمي 1: هل تتحقق معايير النوبة التشّنجية لدى الشخص؟ » سؤال الشخص والقائم على العناية به عّما إذا كان الشخص قد أُصيب بأّي من الأعراض التالية: حركات تشّنجية تدوم أكثر من دقيقة إلى دقيقتين. فقدان أو اختلال الوعي. تصلّب أو تيبّس للبدن أو الأطراف يدوم أكثر من دقيقة إلى دقيقتين. عض أو ازرقاق اللسان أو إصابة بدنية. فقدان السيطرة على المثانة أو الأمعاء في أثناء النوبة. بعد انقضاء الحركات غير الطبيعية، قد يبدو الشخص مشّوشا ًأو نعسانا ًأو يظهر سلوكا ًشاذا.ً قد يشكو أيضا ًمن التعب أو الصداع أو آلام في العضلات. » تتحقق معايير النوبة التشّنجية إن توفرت لدى الشخص حركات تشّنجية وما لا يقل عن عارضين آخرين من الأعراض المذكورة أعلاه. » الاشتباه بنوبات غير تشّنجية أو بحالات طبية أخرى إن توفر معيار واحد أو معياران فقط من المعايير المذكورة أعلاه. استشارة أخصائي إن أصيب الشخص بأكثر من نوبة غير تشّنجية واحدة. معالجة الأمر بما يتوافق في حال الاشتباه بحالات طبية أخرى. متابعة الحالة بعد ۳ أشهر من أجل إعادة التقييم. » البحث عن علامات وأعراض التهاب عصبي: حّمى صداع تهيّج السحايا* )noitatirri laegninem( )مثل تصلّب العنق(. » البحث عن مسّببات أخرى محتملة للتشّنجات أو الاختلاج: إصابة في الرأس اضطراب استقلابي* )ytilamronba cilobatem( )مثل نقص جلوكوز الدم* )aimeacylgopyh( ، نقص الصوديوم* )aimeartanopyh(( التسّمم بالكحول أو المواد المدمنة أو الانقطاع عنها (>> المربع 1 BUS في الصفحة ٨٤) » في حال توفر مسبّب حاد قابل للتمييز للنوبة التشّنجية، معالجة المسّبب. إن المعالجة المداومة بالأدوية المضادة للصرع غير ضرورية في هذه الحالات. » الإحالة فورا ًإلى المستشفى في حال الاشتباه بالتهاب عصبي* )noitcefnioruen(، إصابة في الرأس أو اضطراب استقلابي. الاشتباه بالتهاب عصبي عند طفل )من عمر ستة أشهر إلى ست سنوات( مصاب بالحمى في حال توفر أي من المعايير التالية لنوبات الحمى المعقدة: – نوبة بؤرية - تبدأ النوبة في جزء واحد من الجسم – نوبة مطّولة - تدوم النوبة أكثر من 51 دقيقة – نوبة متكررة - أكثر من نوبة واحدة خلال المرض الحالي » إن لم يتوفر أي من المعايير الثلاثة أعلاه لدى طفل مصاب بالحمى، الاشتباه بنوبة حّمى بسيطة. معالجة الحّمى والبحث عن أسبابها وفقا ً للمبادئ التوجيهية للتدبير المتكامل لأمراض الطفولة ICMI. مراقبة الطفل مدة ٤۲ ساعة. » متابعة الحالة بعد ۳ أشهر من أجل إعادة التقييم. » تعتبر حالة صرع إذا أُصيب الشخص بنوبتين تشّنجيتين أو أكثر لا محفز لهما في يومين مختلفين خلال الأشهر الاثني عشر الماضية. » إذا أُصيب الشخص بنوبة تشّنجية واحدة خلال الأشهر الاثني عشر الماضية من دون مسبّب حاد لها، لا يكون العلاج بالأدوية المضادة للصرع ضروريا.ً متابعة الحالة بعد ۳ أشهر. السؤال التقييمي ۲: هل من مسّبب حاد للنوبة التشّنجية؟ السؤال التقييمي ۳: أمام نوبة تشّنجية من دون تمييز مسّبب حاد لها، هل تكون حالة صرع؟ 83 خطة التدبير الأساسية 1. تثقيف الشخص والقائمين على العناية به بشأن الصرع » الطلب من الشخص والقائمين على العناية به الاحتفاظ بسجل بسيط بالنوبات )راجع الرسم 1 CPG IPE(. » شرح ما يلي: مفهوم الصرع وأسبابه: – الصرع حالة مزمنة. ولكن بفضل الأدوية، ثلاثة من أصل أربعة أشخاص يتخلصون من النوبات. – ينطوي الصرع على نوبات متكررة. النوبة مشكلة ناتجة عن نشاط كهربائي غير طبيعي في الدماغ. – الصرع ليس ناتجا ًعن السحر أو الجن. – الصرع غير معٍد ولا ينتقل باللعاب. المسائل المتعلقة بنمط الحياة ذات الصلة: – الأشخاص المصابون بالصرع يمكنهم أن يعيشوا حياة طبيعية: يمكنهم أن يتزوجوا وأن ينجبوا أطفالاً بصحة جيدة. يمكنهم أن يشغلوا معظم الوظائف بأمان وأن يكونوا منتجين. إن الأطفال المصابين بالصرع يمكنهم الذهاب إلى المدرسة. – على الأشخاص المصابين بالصرع أن يتجنبوا ما يلي: الوظائف التي تتطلب العمل بالقرب من الآلات الثقيلة أو النار طهي الطعام على نار مكشوفة السباحة بمفردهم الكحول ومواد الإدمان الترويحية النظر إلى الأضواء الساطعة تغيير نمط النوم )كالنوم أقل بكثير من المعتاد(. ما يجب عمله في المنزل عند حصول النوبات )رسائل إلى القائمين على العناية بالشخص(: – إن بدأت النوبة فيما الشخص واقف أو جالس، الوقاية من الإصابات الناتجة عن السقوط بمساعدته على الجلوس أو التمّدد على الأرض. – التأكد من أن الشخص يتنفس بشكل طبيعي. إرخاء الثياب حول العنق. – تركيز الشخص في وضعية الإفاقة )راجع الرسوم D - A أدناه(. أ. الجثو على الأرض بجانب الشخص. تثبيت ذراع الشخص القريبة منك عند زاوية قائمة بالنسبة إلى جسده على أن تكون يده موّجهة إلى الأعلى باتجاه رأسه )راجع الرسم A أعلاه(. ب. تثبيت يده الأخرى تحت جانب رأسه بحيث تلامس الجهة الخلفية من يده خدَّ ه )راجع الرسم B أعلاه(. ج. ثني الركبة البعيدة عنك عند زاوية قائمة. قلب الشخص بعناية على جنبه بجذب الركبة المثنيّة )راجع الرسم C أعلاه(. د. إن الذراع العليا للشخص تسند رأسه فيما ذراعه السفلى توقف تدحرجه إلى البعيد )راجع الرسم D أعلاه(. فتح المجرى الهوائي للشخص بإمالة رأسه إلى الوراء بلطف ورفع ذقنه والتأكد من خلو المجرى الهوائي مّما يعيقه. هذه العملية تخرج اللسان من المجرى الهوائي، تساعد الشخص على التنفس بشكل أفضل وتمنع الاختناق بسبب الإفرازات والقيء. – عدم محاولة تقييد أو تثبيت الشخص إلى الأرض. – عدم وضع أي شيء في فم الشخص. – إبعاد الأدوات الحادة أو الصلبة عن الشخص لتفادي الإصابات. – البقاء مع الشخص إلى أن تتوقف النوبة ويستعيد وعيه. الرسوم D - A: وضعية الإفاقة 93 التحّقق مّما إذا سبق للشخص تناول دواء مضاد للصرع ساعده في السيطرة على النوبات. في حال الإيجاب، وصف الدواء نفسه بالجرعة نفسها. » في حال عدم توفر هذا الدواء، وصف دواء جديد. » اختيار دواء واحد مضاد للصرع )مراجعة الجدول 1 IPE(. النظر في الآثار الجانبية المحتملة، والتفاعلات للمرض مع الدواء* )snoitcaretni esaesid-gurd( أو التفاعلات للدواء مع الدواء* )snoitcaretni gurd-gurd( . مراجعة كتيب الوصفات الوطني أو الخاص بمنظمة الصحة العالمية، حسب الضرورة. البدء بإعطاء أدنى جرعة وزيادتها تدريجيا ًحتى السيطرة الكاملة على النوبة. » شرح ما يلي للشخص وللقائمين على العناية به: جدول الجرعات )>> الجدول 1 IPE). الآثار الجانبية المحتملة )>> الجدول 1 IPE(. معظم الآثار الجانبية خفيفة وتزول مع الوقت. في حال حصول آثار جانبية حادة، يجب أن يتوقف الشخص فورا ًعن تناول الدواء وأن يحصل على المساعدة الطبية. أهمية الالتزام بالدواء. إن تفويت الجرعات أو التوقف المفاجئ يمكنهما التسبّب في معاودة النوبات. يجب تناول هذه الأدوية في الوقت نفسه كل يوم. الوقت الضروري قبل أن يعطي الدواء مفعولاً. يحتاج الأمر عادة بضعة أسابيع قبل أن يصبح تأثير الدواء واضحا.ً مدة العلاج. الاستمرار في تناول الدواء حتى انقضاء عامين على الأقل لم تتخلّلهما أية نوبة. أهمية المتابعة المنتظمة. ۲. بدء أو استئناف الأدوية المضادة للصرع الجدول 1IPE: الأدوية المضادة للصرع. فالبرواتفينيتوينكاربامازيبينفينوباربيتالأ الجرعة الابتدائية للأطفال 51 - 02 ملغم/كغم/اليوم3 - ٤ ملغم/كغم/اليوم5 ملغم/كغم/اليوم2 - 3 ملغم/كغم/اليوم الجرعة الفعالة النموذجية للأطفال 51 - 03 ملغم/كغم/اليوم3 - 8 ملغم/كغم/اليوم01 - 03 ملغم/كغم/اليوم2 - 6 ملغم/كغم/اليوم الجرعة الابتدائية للبالغين 002 ملغم/اليوم051 - 002 ملغم/اليوم002 - 00٤ ملغم/اليوم.6 ملغم/اليوم الجرعة الفعالة النموذجية للبالغين 00٤ - 0002 ملغم/اليوم002 - 00٤ ملغم/اليوم00٤ - 00٤1 ملغم/اليوم06 - 081 ملغم/اليوم للأطفال، مرتين في اليوم. للبالغين، مرتين في اليوممرة في اليوم قبل النومجدول الجرعات بالإمكان مرة في اليوم عادة مرتين أو ۳ مرات في اليوم الآثار الجانبية النادرة والخطيرة طفح جلدي حاد )متلازمة ستيفنز جونسون* )-snevetS emordnys nosnhoJ( كبت نخاع العظم* )enob noisserped worram( فشل كبدي طفح جلدي حاد )متلازمة ستيفنز جونسون* )nosnhoJ-snevetS emordnys(، تقشر الأنسجة المتموتة البشروية التسممي* )sisylorcen lamredipe cixot( كبت نخاع العظم* )enob noisserped worram( فقر الدم وتشوهات الدم الأخرى فرط الحساسية بما ذلك الطفح الجلدي الحاد )متلازمة ستيفنز جونسون* )nosnhoJ-snevetS emordnys( التهاب الكبد نعاس تشّوش الآثار الجانبية الشائعة نعاس فرط الحركة عند الأطفال نعاس صعوبة في المشي غثيان غثيان، تقيؤ، إمساك عراش نعاس ترنّح وصعوبة في النطق حركات مرتعشة تشّوش ذهني خمول شعور بالخدر رعاش غثيان، إسهال زيادة في الوزن فقدان شعر عابر )ينمو عادة في غضون 6 أشهر( اختلال وظائف الكبد تجّنب الفينوباربيتال للأطفال المحاذير المصابين بإعاقة ذهنية أو لديهم مشاكل سلوكية تجّنب الفالبروات للنساء الحوامل أ متوفر في المجموعة الصحية المشتركة بين الوكالات لحالات الطوارئ )منظمة الصّحة العالمية، 1102(. 04 » توفير متابعة منتظمة تحديد مواعيد متابعة منتظمة بتواتر مرة في الشهر على الأقل خلال الأشهر الثلاثة الأولى أو حتى السيطرة على النوبات. مقابلة الشخص مرة كل ۳ أشهر بعد السيطرة على النوبات. الانتقال إلى مبادئ التدبير (>> المبادئ العامة للرعاية) للحصول على المزيد من التوجيهات المفّصلة الخاصة بالمتابعة. » في كل جلسة متابعة: مراقبة السيطرة على النوبات: – مراجعة سجل النوبات للتحقق من مدى السيطرة على النوبات. مواصلة العلاج بمضاد الصرع أو تعديله وفقا ًلمدى السيطرة على النوبات. – إن لم تتم السيطرة بعد على النوبات بالجرعة العلاجية القصوى لمضاد صرع واحد أو إن أصبحت الآثار الجانبية غير محتملة، استبداله بدواء آخر. زيادة الجرعة تدريجيا ًحتى السيطرة على النوبات. – إذا كانت النوبات نادرة جدا ًوكانت أية زيادة للجرعة قد تنتج آثارا ًجانبية حادة، تكون حينئذ الجرعة الحالية مقبولة. – استشارة طبيب متخّصص إن تمّت تجربة دواءين الواحد تلو الآخر ولم ينجح أحدهما في السيطرة على النوبات بشكل ملائم. تجّنب العلاج بأكثر من مضاد صرع واحد في آن واحد. النظر في إيقاف مضاد الصرع إن لم تحصل أية نوبة في العامين المنصرمين. – عند إيقاف مضاد الصرع، يجب تقليل الجرعة تدريجيا ًعلى امتداد بضعة أشهر لتفادي النوبات الناتجة عن الانقطاع عن الدواء. إشراك القائمين على العناية بالشخص في مراقبة السيطرة على النوبات. مراجعة المسائل المتعلقة بنمط الحياة وتقديم المزيد من التثقيف النفسي/الدعم للشخص والقائمين على العناية به )>> الخطوة 1 من خطة التدبير الأساسية أعلاه(. ۳. المتابعة الرسم 1 IPE: مثال عن سجل نوبات وصف النوبة (بما في ذلك أعضاء متى حدثت النوبة الجسم المتأثرة ومدة النوبة) الأدوية التي تناولها الشخص اليومفي الأمسالوقتالتاريخ » إذا كانت المرأة في سن الإنجاب: وصف الفولات 5 ملغم/اليوم لتفادي التشوهات الخلقية الممكنة إذا أصبحت المرأة حاملاً. » إذا كانت المرأة حامًلا: استشارة طبيب متخّص ص لمعالجة حالتها. إعلام المرأة بضرورة زيادة عدد الزيارات السابقة للولادة وبإنجاب مولودها في المستشفى. عند الولادة، إعطاء 1 ملغم من الفيتامين ك بالعضل لحديثي الولادة. » يجب إشراك المرأة الحامل في اتخاذ قرار البدء بمضاد صرع. يجب أن تؤخذ بعين الاعتبار حّدة النوبات وتواترها فضًلا عن الأذى المحتمل الذي قد يلحقه مضاد الصرع أو تلحقه النوبات بالجنين. في حال اتخاذ القرار ببدء مضاد صرع، يمكن وصف الفينوباربيتال أو الكاربامازيبين. يجب تفادي الفالبروات والعلاج متعدد الأدوية* )yparehtylop(. » يمكن وصف الكاربامازيبين للنساء المرضعات. المربع 1 IPE: إعتبارات خاصة لعلاج النساء المصابات بالصرع 14 » تقييم النوبات: الحفاظ على الهدوء. معظم النوبات تتوقف بعد بضعة دقائق. تفقد المجرى الهوائي والتنفس والدورة الدموية بما في ذلك ضغط الدم ومعدل التنفس ودرجة الحرارة. البحث عن علامات حدوث إصابة في الرأس أو العمود الفقري )على سبيل المثال، إن توّسع الحدقتين قد يشير إلى إصابة قوية في الرأس(. البحث عن تصلب العنق أو الحمى )علامات على وجود التهاب السحايا(. » سؤال القائم على العناية بالشخص: متى بدأت هذه النوبة؟ هل للشخص تاريخ من النوبات؟ هل للشخص تاريخ من الإصابات في الرأس أو العنق؟ هل يعاني الشخص من مشاكل طبية أخرى؟ هل سبق للشخص أن تناول أي دواء أو سّم أو كحول أو مواد مدمنة؟ إذا كان الشخص أنثى: هل هي في النصف الثاني من الحمل أو في الأسبوع الأول بعد الولادة؟ » الإحالة فورا ًإلى المستشفى: في حال وجود أية علامة لإصابة رئيسية، صدمة* )kcohs( أو مشكلة في التنفس. إذا أصيب الشخص بإصابة قوية في الرأس أو العنق: – لا يجب تحريك عنق الشخص. – تطبيق تقنية * llor-goL عند نقل الشخص. إذا كان الشخص أنثى في النصف الثاني من الحمل أو ما دون أسبوع بعد الولادة. في حال الاشتباه بالتهاب عصبي. في حال ُمضي أكثر من 5 دقائق منذ بدء النوبة. » معالجة النوبات: وضع الشخص على جنبه في وضعية الإفاقة )مراجعة خطة التدبير الأساسية والرسوم D - A أعلاه(. إن لم تتوقف النوبة تلقائيا ًبعد دقيقة إلى دقيقتين، فتح خط وريدي في أسرع وقت ممكن واعطاء الجلوكوز والبنزوديازيبين ببطء )03 نقطة/الدقيقة(. – إذا كان من الصعب فتح خط وريدي، إعطاء البنزوديازيبين بالمستقيم. – تحذير: بإمكان البنزوديازيبين إبطاء التنفس. إعطاء الشخص الاكسجين إن توفر ومراقبة معدل تنفسه على نحو متكّرر. – جرعة الجلوكوز للأطفال: 2 - 5 مل/كغم في 01% من الجلوكوز. – جرعة البنزوديازيبين للأطفال: الديازيبام بالمستقيم 2.0 - 5.0 ملغم/كغم أو الديازيبام بالوريد 1,0 - 3.0 ملغم/كغم أو اللورازيبام بالوريد 1.0 ملغم/كغم – جرعة الجلوكوز للبالغين: 52 - 05 مل في ∙5% من الجلوكوز – جرعة البنزوديازيبين للبالغين: الديازيبام بالمستقيم 01 - 02 ملغم أو الديازيبام بالوريد 01 - 02 ملغم ببطء أو اللورازيبام بالوريد ٤ ملغم. – عدم إعطاء البنزوديازيبين بالعضل. إعطاء جرعة ثانية من البنزوديازيبين إذا استمرت النوبة مدة 5 - 01 دقائق بعد الجرعة الأولى. يجب أن تكون الجرعة الثانية مساوية للجرعة الأولى. عدم إعطاء الشخص أكثر من جرعتين من البنزوديازيبين. إذا احتاج لأكثر من جرعتين، يجب إرساله إلى المستشفى. الاشتباه بحالة صرعية إذا: – تكّررت النوبات ولا شفاء بين النوبات، – أو النوبات لا تستجيب لجرعتين من البنزوديازيبين، – أو النوبات تدوم أكثر من 5 دقائق. » الإحالة فورا ًإلى المستشفى: في حال الاشتباه بحالة صرعية )راجع أعلاه(. إن لم يستجب الشخص لأول جرعتين من البنزوديازيبين. إذا كان الشخص يعاني من مشاكل في التنفس بعد تناول البنزوديازيبين. المربع 2 IPE : تقييم وعلاج شخص مصاب بتّشنجات أو فاقد للوعي بعد تعرّضه لنوبة يجب تقييم وعلاج النوبات الحادة بشكل متزامن 24 الإعاقة الذهنية تّتسم الإعاقة الذهنية٩ بالمحدودية غير القابلة للعكس في جوانب عديدة من النمو الذهني المتوقع (كالمهارات المعرفية* (evitingoc) واللغوية والحركية والاجتماعية). هذه المحدودية قائمة منذ الولادة أو بدأت في مرحلة الطفولة. إن الإعاقة الذهنية تعيق عملية التعلم والأداء الوظيفي اليومي والتكّيف مع بيئة جديدة. الأشخاص المصابون بإعاقة ذهنية بحاجة غالبا ًإلى خدمات رعاية جوهرية ويواجهون في كثير من الأحيان التحديات في الوصول إلى الرعاية الصحية والتعليم. هم شديدو التأثر بالإساءة والإهمال ومعرضون لأوضاع خطيرة ضمن بيئات الطوارئ المضطربة. على سبيل المثال، من الممكن جدا ًأن يتجّول الأشخاص المصابون بإعاقة ذهنية في المناطق الخطيرة دون التنّبه للأمر. فضلاً عن ذلك، قد يشكلون عبئا ًعلى أسرهم ومجتمعاتهم وقد يتعرّضون للهجر في أثناء النزوح. بالتالي، هم بحاجة إلى المزيد من الانتباه خلال حالات الطوارئ الإنسانية. تغطي هذه الوحدة الإعاقة الذهنية المتوسطة والحادة والشديدة لدى الأطفال والمراهقين والبالغين. الشكاوى النموذجية » لدى الرضع: صعوبة في الرضاعة، إخفاق في النمو، ضعف عضلي حركي، تأخر في بلوغ مقاييس النمو المتوقعة المتناسبة مع سن الرضيع ومرحلة نموه مثل الابتسام والجلوس والوقوف. » لدى الأطفال: تأخر في بلوغ مقاييس النمو المتوقعة المتناسبة مع سن الطفل مثل المشي والتدّرب على استخدام المرحاض والنطق والقراءة والكتابة. » لدى البالغين: ضعف القدرة على العيش مستقلين أو رعاية أنفسهم و/أو أطفالهم. » لدى كافة الفئات العمرية: صعوبة في الاضطلاع بالأنشطة اليومية التي تعتبر عادية بالنسبة إلى عمر الشخص، صعوبة في فهم التعليمات، صعوبة في تلبية الحاجات اليومية. 3411-DCI9 إن المراجعة الحادية عشرة للتصنيف الدولي للأمراض تطلق على هذا الاضطراب اسم اضطراب النمو الذهني. التقييم السؤال التقييمي 1: هل يعاني الشخص من إعاقة ذهنية؟ » مراجعة مهارات الشخص وأدائه: بالنسبة إلى الأطفال الصغار وحديثي المشي، تقييم ما إذا بلغ الطفل تماما ًمقاييس النمو المتناسبة مع سّنه على كافة المستويات )>> المربع 1 DI، الإشارات التحذيرية(. الأسئلة المقترحة للقائمين على العناية بالأطفال: – هل يتصرف طفلك كما يتصرف أطفال آخرون في نفس سنه؟ – ما هي الأمور التي يستطيع طفلك القيام بها وحده )الجلوس، المشي، تناول الطعام، ارتداء الملابس أو استخدام المرحاض(؟ – كيف يتواصل طفلك معك؟ هل يبتسم لك؟ هل يستجيب عندما تنادي اسمه/اسمها؟ كيف يتحدث معك؟ هل هو قادر على طلب ما يريد؟ – كيف يلعب طفلك؟ هل هو قادر على اللعب جيدا ًمع أطفال آخرين في نفس سّنه؟ بالنسبة إلى الأطفال الأكبر سنا ًوالمراهقين، السؤال عّما إذا كانوا يذهبون إلى المدرسة وفي هذه الحال كيف يتّممون واجباتهم المدرسية )مثل التعلم والقراءة والكتابة( والمهام المنزلية اليومية. – هل تذهب إلى المدرسة؟ كيف حال دراستك؟ هل أنت قادر على إتمام واجباتك المدرسية؟ هل تواجه الصعوبات في المدرسة غالبا ً لأنك لا تستطيع فهم التعليمات أو اتباعها؟ بالنسبة إلى البالغين، السؤال عّما إذا كانوا يعملون وفي هذه الحال كيف يتدبرون المهام المهنية وغيرها من الأنشطة اليومية. – هل تعمل؟ ما نوع المهنة التي تزاولها؟ هل تواجه المشاكل في عملك غالبا ًلأنك لا تستطيع فهم التعليمات أو اتباعها؟ بالنسبة إلى الأطفال الأكبر سنا ًوالمراهقين والبالغين، السؤال عن مقدار المساعدة التي يحصل عليها الشخص حاليا ًللاضطلاع بمهامه اليومية )على سبيل المثال، في المنزل والمدرسة والعمل(. » إن كان هناك تأخر في بلوغ مقاييس النمو المتوقعة، استبعاد الحالات المرضيّة القابلة للعلاج أو القابلة للعكس التي يمكنها أن تشبه الإعاقة الذهنية. استبعاد ضعف النظر: – لطفل فوق الستة أشهر، سؤال القائم على العناية به عّما إذا كان الطفل قادرا ًعلى فعل ما يلي ذكره في حين أنك تراقب الطفل بنفسك مباشرة: إن كان الطفل قادرا ًعلى تتبّع جسم متحرك بعينيه إن كان الطفل قادرا ًعلى التعرّف إلى أشخاص مألوفين إن كان الطفل قادرا ًعلى التقاط غرض بين يديه – إن كانت الإجابة بالنفي على أي من الاسئلة السابقة، إبلاغ القائم على العناية بالطفل بأن الطفل قد يكون مصابًا بضعف نظر واستشارة طبيب مختص إن توفر. استبعاد ضعف السمع: – لطفل فوق الستة أشهر، سؤال القائم على العناية به عّما إذا كان الطفل قادرا ًعلى فعل ما يلي ذكره في حين أنك تراقب الطفل بنفسك مباشرة: إن كان الطفل يدير رأسه لرؤية المتكلم من الخلف إن كان الطفل يبدي ردود فعل على الأصوات الصاخبة إن كان الطفل يصدر أصواتا ًمختلفة )تاتا، دادا، بابا(. – إن كانت الإجابة بالنفي على أي من الاسئلة السابقة، إبلاغ القائم على العناية بالطفل بأن الطفل قد يكون مصابا ًبضعف سمع واستشارة طبيب مختص إن توفر. استبعاد المشاكل الموجودة ضمن البيئة المحيطة بالطفل: – إصابة الأم أو القائم الرئيسي على العناية بالطفل باضطراب اكتئابي معتدل إلى حاد )>> PED( – غياب التحفيز )التحفيز أساسي لنمو دماغ الأطفال الصغار(. من يتفاعل بانتظام مع طفلك ويلعب معه؟ كيف تلعب أو يلعب الأشخاص الآخرون مع طفلك؟ وبأي وتيرة؟ كيف تتواصل أو يتواصل الأشخاص الآخرون مع طفلك؟ وبأي وتيرة؟ استبعاد سوء التغذية وأي نقص تغذوي أو هورموني بما في ذلك نقص اليود* )ycneicfied enidoi( وقصورد الغدة الدرقية* )msidioryhtopyh(. استبعاد الصرع (>> IPE(، الذي يمكن أن يحاكي الإعاقة الذهنية أو التزامن معها. » معالجة المشاكل المستكشفة القابلة للعلاج والمتابعة من أجل إعادة تقييم ما إذا كان الشخص مصابا ًبإعاقة ذهنية. بالنسبة إلى حالات ضعف السمع والبصر المؤكدة، توفير الأجهزة المناسبة )العدسات، المعينات السمعية( أو المطالبة بها. عند الاقتضاء، معالجة الاضطراب الاكتئابي لدى القائم على العناية بالشخص. تعليم القائم على العناية بالشخص كيفية توفير بيئة أكثر تحفيزا ً للأطفال الصغار. مراجعة إسداء المشورة للأسرة بشأن رعاية النمو: بطاقات المشورة )منظمة الصحة العالمية واليونيسف، 2102(. عند الاقتضاء، إحالة الشخص إلى برامج تنمية الطفولة المبكرة )DCE(. » إن إصابة الشخص بإعاقة ذهنية أمر محتمل إذا )أ( كان هناك تأخر هام في بلوغ مقاييس النمو المتوقعة وصعوبة في تلبية الحاجات اليومية و)ب( تّم استبعاد أو معالجة الحالات القابلة للعلاج أو القابلة للعكس. » عدم الاستماع للقائمين على العناية به » نوبات غضب. سلوك عدائي و ايذاء الذات عند الشعور بالغضب. » استهلاك المواد غير العضوية » سلوك جنسي متهوّر أو سلوك شاذ آخر. السؤال التقييمي ۲: هل يعاني الشخص من مشاكل سلوكية متزامنة؟ 44 خطة التدبير الأساسية 1. توفير التثقيف النفسي ۲. تعزيز الحماية المجتمعية ۳. المطالبة بإشراك الأشخاص المصابين بإعاقة ذهنية في الأنشطة المجتمعية 5. إن أمكن، الإحالة إلى طبيب متخّصص من أجل التوّسع في تقييم وعلاج الاضطرابات النمائية المتزامنة المحتملة ٦. المتابعة ٤. تقديم الرعاية للقائمين على العناية بالأشخاص وفقا ًلمبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية) » شرح الإعاقة للشخص وللقائمين على العناية به. لا يجب لوم الأشخاص المصابين بإعاقة ذهنية على إعاقتهم. بالنسبة إلى القائمين على العناية بالشخص، يجب أن تكون توقعاتهم واقعية وأن يدعموا الشخص ويعاملوه بلطف. » توفير التدريب على مهارات الرعاية الوالدية بهدف تحسين التفاعل الإيجابي بين الأهل/القائم على العناية بالشخص والطفل. تدريب القائمين على العناية بالشخص على المهارات القادرة على تقليص المشاكل السلوكية لديه. إن القائمين على العناية بالشخص يجب أن يدركوا أهمية تعليم الشخص كيفية الاعتناء بنفسه والاهتمام بنظافته الشخصية )كالتدريب على استخدام المرحاض وتنظيف الأسنان(. إن القائمين على العناية بالشخص يجب أن يعرفوا الشخص تمام المعرفة، أن يعلموا ما يزعجه وما يسعده، ما يثير المشاكل السلوكية لديه وما يمنعها، ما هي نقاط الضعف ونقاط القوة لديه وما هي أفضل طريقة للتعلم بالنسبة إليه. إن القائمين على العناية بالشخص يجب أن يحافظوا بقدر الإمكان على أنشطة يومية منتظمة للشخص مثل تناول الطعام، اللعب، التعلم، العمل والنوم. إن القائمين على العناية بالشخص يجب أن يكافئوا الشخص عندما يُحسن التصرف وأن يحجبوا عنه المكافأة عندما يسيء التصرف. يجب التوازن في التأديب: – إعطاء تعليمات واضحة، بسيطة ومختصرة عّما ينبغي للشخص القيام به بدلاً مّما لا ينبغي له القيام به. تقسيم الأنشطة المعقدة إلى خطوات أصغر بحيث يكون الشخص قادرا ًعلى التعلم بشكل تدريجي فيكافأ عن كل خطوة )مثل تعلم كيفية ارتداء البنطال قبل قفل الأزرار(. – عندما يحسن الشخص التصرف، تجدر مكافأته. إلهاء الشخص عن الأشياء التي لا ينبغي له القيام بها، إلا أن هذا الالهاء لا يجب أن يكون أمرا ًممتعا ًأو مجزيا ًللشخص. – عدم اللجوء إلى التهديد أو العقوبات الجسدية عندما يكون سلوك الشخص غير مقبول. » تثقيف القائمين على العناية بالشخص بأن الشخص المصاب بإعاقة ذهنية أكثر تعرضا ًبشكل عام للاعتداء الجنسي والجسدي لذا فهو يستلزم المزيد من الاهتمام والحماية. » إبلاغ القائمين على العناية بالشخص أن يتجّنبوا إدخال الشخص إلى مؤسسات الرعاية. » تقييم ما إذا كانت تتوفر الحماية المجتمعية )مثل المجموعات غير الرسمية، المنظمات غير الحكومية المحلية، الوكالات الحكومية أو الوكالات الدولية( وطلب الدعم المناسب للشخص. » إذا كان الشخص طفلاً، إبقاؤه في مدارس التعليم العام بقدر الإمكان. إقامة الروابط مع مدرسة الطفل لاستكشاف إمكانية تكييف البيئة التعليمية وفقا ًلحاجات الطفل. تتوفر بعض النصائح البسيطة في التعليم الجامع للأطفال المعرضين للخطر )EENI(. التشجيع على المشاركة في الأنشطة الاجتماعية الممتعة داخل المجتمع. تقييم ما إذا كانت تتوفر برامج إعادة التأهيل المجتمعية )RBC-noitatilibaher desab-ytinummoc*( والمطالبة بإشراك الأشخاص المصابين بإعاقة ذهنية في مثل هذه البرامج. » الإعاقة الحركية غير القابلة للعكس أو الشلل الدماغي* )larberec yslap( » التشوهات الخلقية، الشذوذ الوراثي أو المتلازمات الوراثية )مثل متلازمة داون* )emordnys nwoD(( » ترتيب جلسات متابعة منتظمة واجراؤها وفقا لمبادئ التدبير (>> المبادئ العامة للرعاية) 54 المربع 1 DI : مقاييس النمو: الإشارات التحذيرية الواجب التنبّه لها في عمر الشهر صعوبة الرضاعة من الثدي أو رفض الرضاعة ضعف حركة الذراعين والساقين ضعف أو غياب ردود الفعل على الأصوات الصاخبة أو الأضواء الساطعة البكاء مدة طويلة من دون سبب واضح التقيؤ والإسهال، اللذان قد يسبّبان الجفاف تصلّب أو صعوبة في تحريك الأطراففي عمر الستة أشهر تحريك متواصل للرأس )مّما قد يدل على التهاب الأذن، الذي قد يؤدي إلى الصمم إن لم يُعالج( ضعف أو غياب الاستجابة للأصوات أو الوجوه المألوفة أو الثدي رفض الثدي أو طعام آخر عدم إصدار الأصوات استجابة للآخرينفي عمر الاثني عشر شهراً عدم النظر إلى الأجسام المتحركة عدم الاكتراث وغياب الاستجابة للقائم على العناية به فقدان الشهية أو رفض الطعام عدم الاستجابة للآخرينفي عمر السنتين صعوبة التوازن في أثناء المشي الكدمات والتغيرات السلوكية غير المفّسرة )لاسيّما إن تولى غرباء العناية بالطفل( فقدان الشهية فقدان الاهتمام باللعبفي عمر الثلاث سنوات سقوط متكرر صعوبة في التقاط الأشياء الصغيرة إخفاق في فهم الرسائل البسيطة عدم القدرة على النطق بعدة كلمات ضعف أو غياب الاهتمام بالطعام خوف، غضب أو عنف في أثناء اللعب مع أطفال آخرين، مّما قد يدل على إساءة أو مشاكل عاطفيةفي عمر الخمس سنوات صعوبة في كسب الأصدقاء والحفاظ عليهم، وفي المشاركة في الأنشطة الجماعيةفي عمر الثماني سنوات تجنب مهّمة أو تحٍد من دون المحاولة، أو إظهار علامات عجز صعوبة في التعبير عن الحاجات والأفكار والمشاعر صعوبة في التركيز على المهام، في فهم الواجبات المدرسية واتمامها عدائية أو خجل مفرط مع الأصدقاء والأسرة المصدر: منظمة الأمم المتحدة للطفولة، منظمة الصحة العالمية، منظمة الأمم المتحدة للتربية والعلوم والثقافة، صندوق الأمم المتحدة للسكان، برنامج الأمم المتحدة الإ نمائي، برنامج الأمم المتحدة المشترك المعني بفيروس نقص المناعة البشرية/الايدز، برنامج الأغذية العالمي والبنك الدولي (0102) 64 74 التعاطي الضار للكحول ومواد الإدمان إن تعاطي الكحول أو مواد الإدمان (مثل الافيونات* (setaipo) )كالهيروين)، القنب* (sibannac)، الامفيتامينات* (senimatehpma)، القات* (tahk)، الأدوية الموصوفة المختلفة مثل البنزوديازيبين* (enipezaidozneb) والترامادول* (lodamart)) يمكنه أن يسّبب مشاكل متنوعة، ومنها الانقطاع (أي الأعراض الجسدية والنفسية التي تظهر عند وقف أو التقليل من التعاطي بشكل ملحوظ)، والاعتماد* (ecnedneped) والتعاطي الضار (الأذى الذي يلحق بالصحة الجسدية أو النفسية و/أو الرفاه العام). إن تعاطي الكحول أو مواد الإدمان أمر ضار عندما يكون مسؤولاً عن الاضطرابات الجسدية أو النفسية، السلوك الصحي الخطير، المشاكل العائلية أو المشاكل في العلاقات، العنف الجسدي والجنسي، الحوادث، الإساءة إلى الأطفال واهمالهم، الصعوبات المالية وغيرها من المسائل المتعلقة بالحماية. إن التعاطي الضار للكحول أو مواد الإدمان قد يزداد انتشارا ًفي حالات الطوارئ الإنسانية حيث أن البالغين والمراهقين يحاولون التصّدي للضغط النفسي أو الخسارة أو الألم بالتطبيب الذاتي* (-fles gnitacidem). في حالات الطوارئ الشديدة، قد تختل إمدادات الكحول أو مواد الإدمان فتتسّبب بأعراض انقطاع غير متوقعة تهّدد حياة الأشخاص الذين اعتادوا منذ زمن طويل استهلاك المواد المدمنة بجرعات عالية نسبيا.ً هذا ينطبق بشكل خاص على الكحول. تركز هذه الوحدة على التعاطي الضار للكحول أو مواد الإدمان وتنطوي على مربع يتعلق بالانقطاع عن الكحول الذي يشكل خطرا ًعلى حياة الشخص (>> المربع 1 BUS). أما بالنسبة إلى الجوانب الأخرى لتعاطي الكحول أو مواد الإدمان، فتجدر مراجعة الوحدتين المتعلقتين بتعاطي الكحول واستخدام مواد الإدمان في الدليل الكامل لتدخلات برنامج رأب الفجوة في الصحة النفسية. الشكاوى النموذجية » يبدو الشخص تحت تأثير الكحول أو مواد الإدمان (على سبيل المثال، تفوح منها رئحة كحول، يبدو مخمورا،ً يعاني من الاهتياج، التململ، تدني مستوى الطاقة، صعوبة في النطق، يظهر بمظهر غير مهذب، حدقتاه متوّسعتان/منقبضتان* (slipup detcirtsnoc/detalid)) » إصابة حديثة » علامات استخدام مواد الإدمان بالوريد (علامات حقن، عدوى جلدية) » طلب الأقراص المنّومة أو مسكّنات الألم. مراجعة المربع 1 BUS في الصفحة ٨٤ المتعلق بتقييم وتدبير الانقطاع عن الكحول الذي يشكل خطرا ً على حياة الشخص. التقييم السؤال التقييمي 1: هل يلحق تعاطي الكحول أو مواد الإدمان الأذى بالصحة الجسدية أو النفسية و/أو بالرفاه العام للشخص؟ » التحقيق في تعاطي الكحول أو مواد الإدمان بطريقة لا تنّم عن أحكام. » السؤال عّما يلي: الكمية ونمط التعاطي أو الاستخدام – هل تشرب الكحول؟ في حال الإيجاب، بأي شكل؟ كم مشروب تتناول في اليوم/الأسبوع؟ – هل تتناول الأقراص المنّومة/الحبوب المضادة للقلق/مسّكنات الألم الموصوفة؟ أي نوع منها؟ كم عددها في اليوم/الأسبوع؟ – هل تستخدم مواد الإدمان غير المشروعة؟ أي نوع منها؟ ما هي طريقة الاستخدام–عن طريق الفم، الحقن، الاستنشاق؟ ما الكمية/التواتر في اليوم/الأسبوع؟ دوافع استخدام الكحول أو مواد الإدمان – ما الذي يجعلك ترغب في تعاطي الكحول أو مواد الإدمان؟ الأذى للنفس أو للآخرين – المشاكل الطبية أو الإصابات الناجمة عن تعاطي الكحول أو مواد الإدمان. هل عانيت من مشاكل صحية منذ أن بدأت بشرب الكحول أو استخدام مواد الإدمان؟ هل تعرضت يوًما للإصابة حينما كنت تحت تأثير الكحول أو مواد الإدمان؟ – الاستهلاك المتواصل للكحول أو مواد الإدمان على الرغم من النصح بالتوقف. عندما كانت المرأة حاملاً أو مرضعة. عندما أ بلغ الشخص بأنه يعاني من مشكلة في المعدة أو الكبد بسبب شرب الكحول أو استخدام مواد الإدمان. عندما كان الشخص يتناول الأدوية ذات التفاعلات الضارة مع الكحول أو مواد الإدمان، مثل المهّدئات أو المسّكنات أو أدوية السل. – المشاكل الاجتماعية الناجمة عن تعاطي الكحول أو مواد الإدمان: المشاكل المالية أو القانونية هل عانيت يوما ًمن مشاكل مالية أو خالفت القانون بسبب تعاطي الكحول أو مواد الإدمان؟ المشاكل المهنية هل خسرت يوما وظيفة أو كان أداؤك في العمل سيئا بسبب تعاطي الكحول أو مواد الإدمان؟ صعوبة في العناية بالأطفال أو بمُعالين آخرين هل وجدت يوما ًصعوبة في رعاية طفلك/أسرتك بسبب تعاطي الكحول أو مواد الإدمان؟ العنف تجاه الآخرين هل أذيت يوما ًأحدا ًفي أثناء تعاطي الكحول أو مواد الإدمان؟ المشاكل في العلاقات/الحياة الزوجية هل سّبب لك يوما تعاطي الكحول أو مواد الإدمان مشكلة مع الشريك؟ » إجراء فحص بدني عام سريع للبحث عن علامات تعاٍط مزمن للكحول أو مواد الإدمان نزيف معدي معوي – آلام البطن – دم في القيء – دم في البراز أو براز أسود أمراض الكبد – الحادة: اليرقان، استسقاء البطن* )seticsa(، كبد وطحال متضخمان ومتصلبان، اعتلال الدماغ الكبدي* )citapeh yhtapolahpecne( سوء التغذية، فقدان الوزن الشديد وجود دليل على عدوى مرتبطة باستخدام مواد الإدمان )مثل فيروس نقص المناعة البشرية، التهاب الكبد ب أو ج، التهابات جلدية في مواقع الحقن، أو السل(. » تقييم التعاطي الضار للكحول ومواد الإدمان على السواء عند الشخص نفسه بما أن المشكلتين تقترنان معا ًفي كثير من الأحيان. 84 خطة التدبير الأساسية 1. تدبير التأثيارات الضارة لتعاطي الكحول أو مواد الإدمان ۲. تقييم الحوافز التي تدفع الشخص لوقف أو التقليل من تعاطي الكحول أو مواد الإدمان ۳. تحفيز الشخص لوقف أو التقليل من تعاطي الكحول أو مواد الإدمان ٤. مناقشة الأساليب المختلفة لوقف أو التقليل من التعاطي الضار 5. توفير الدعم النفسي الاجتماعي كما هو موصوف في مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية) » توفير الرعاية الطبية الضرورية لما يترتّب عن تعاطي الكحول أو مواد الإدمان من أذى جسدي. » تدبير الحالات النفسية المتزامنة، مثل الاضطراب الاكتئابي المعتدل إلى الحاد، اضطراب الكرب ما بعد الصدمة والذهان )>> YSP ,DSTP ,PED(. » معالجة النتائج الاجتماعية الملّحة )مثل الربط بخدمات الحماية في حال الاعتداء كالعنف المبني على أساس النوع الاجتماعي(. » تقييم ما إذا كان الشخص ينظر إلى تعاطي الكحول أو مواد الإدمان على أنه مشكلة وإن كان مستعدا ًللتصرّف حيال الأمر. هل تظن أنه لديك مشكلة تتعلق بالكحول أو مواد الإدمان؟ هل فكرت يوما بوقف أو التقليل من تعاطي الكحول أو مواد الإدمان؟ هل سبق لك أن حاولت وقف أو التقليل من تعاطي الكحول أو مواد الإدمان » إجراء حديث تحفيزي قصير مع الشخص حول التعاطي الضار: سؤال الشخص عن منافع وأضرار تعاطي الكحول أو مواد الإدمان بحسب اعتقاده. عدم إصدار الأحكام، إنما محاولة فهم الأسباب التي تدفعه إلى تعاطي الكحول أو مواد الإدمان. – ما المتعة التي يمنحك إياها تعاطي الكحول أو مواد الإدمان؟ – هل ترى أية جوانب سلبية لتعاطي الكحول أو مواد الإدمان؟ – هل ندمت يوما على تعاطي الكحول أو مواد الإدمان؟ تحّدي أي ادعاء مبالغ به لفوائد تعاطي الكحول أو مواد الإدمان. على سبيل المثال، إذا كان الشخص يتعاطى الكحول أو مواد الإدمان لنسيان مشاكل الحياة، التوّجه إليه بالقول: – هل تناسي المشكلة أمر جّيد حقاً؟ هل يبّدد المشكلة فعلاً؟ التشديد على بعض الجوانب السلبية لتعاطي الكحول أو مواد الإدمان التي يقلل الشخص من أهميتها. – كم من المال تنفق لشراء الكحول أو مواد الإدمان؟ في الأسبوع؟ في الشهر؟ في السنة؟ ماذا يمكنك فعله بهذا المال غير ذلك؟ إعطاء معلومات إضافية بشأن التأثيرات الضارة للكحول ومواد الإدمان سواء على المدى الطويل أو القصير. – قد تسّبب الكحول أو مواد الإدمان المشاكل النفسية والطبية الخطيرة، بما في ذلك الإصابات والإدمان. التنويه بأن وقف تعاطي الكحول أو مواد الإدمان أمر صعب. إعلام الشخص باستعدادك لدعمه. تشجيعه لأن يقّرر بنفسه إن كان وقف تعاطي الكحول أو مواد الإدمان فكرة صائبة. إذا ظّل الشخص غير مستعد لوقف أو التقليل من تعاطي الكحول أو مواد الادمان، احترام قراره. الطلب منه العودة في وقت آخر لمواصلة الحديث. » تكرار الحديث التحفيزي القصير الموصوف أعلاه في جلسات عديدة. » مناقشة الاستراتيجيات التالية: – عدم الاحتفاظ بالكحول أو مواد الإدمان في المنزل. – عدم الاقتتراب من الأماكن التي يتعاطى فيها الأشخاص الكحول أو مواد الإدمان. – طلب دعم الأصدقاء والقائمين على العناية بالشخص. – الطلب من القائمين على العناية بالشخص مرافقته في زيارات المتابعة. – تشجيع الأنشطة الاجتماعية التي لا تتخللها كحول أو مواد إدمان. » النظر في الإحالة إلى مجموعة مساعدة ذاتية تُعنى بتعاطي الكحول أو مواد الإدمان، إن توفرت. » إذا وافق الشخص على وقف تعاطي الكحول أو مواد الإدمان، تحذيره من إمكانية ظهور أعراض انقطاع مؤقتة )مثلاً في أقل من أسبوع(. وصف الأعراض )كالقلق والانفعال بعد الانقطاع عن الأفيونات والبنزوديازيبين والكحول(. التنبيه بضرورة العودة إلى العيادة في حال اشتداد الأعراض. » التعامل مع الضغوطات النفسية الاجتماعية الحالية » تعزيز الدعم الاجتماعي » تعليم كيفية التعامل مع الضغط النفسي 94 المربع 1BUS: تقييم وتدبير الانقطاع عن الكحول الذي يشكل خطرا ًعلى حياة الشخص الشكاوى النموذجية لشخص يعاني من انقطاع عن الكحول يشكل خطرا ًعلى حياته » الاهتياج والقلق الحاد » التشّوش أو الهلوسات* )snoitanicullah( )رؤية أو سماع أو الإحساس بأشياء غير موجودة( » الاختلاجات/النوبات » ارتفاع ضغط الدم 1 )مثلاً > 081/001 ملم زئبق( و/أو ارتفاع في معّدل ضربات القلب )مثلاً > 001 نبضة في الدقيقة(. تقييم الانقطاع عن الكحول الذي يشكل خطرا ًعلى حياة الشخص السؤال التقييمي 1: هل يعاني الشخص من انقطاع عن الكحول؟ » استبعاد ومعالجة الأسباب الأخرى التي يمكنها أن تفّسر الأعراض، بما في ذلك: الملاريا، فيروس نقص المناعة البشرية/الايدز، العدوى الأخرى، الإصابة في الرأس، الاضطرابات الاستقلابية* )cilobatem ytilamronba( )على سبيل المثال، نقص جلوكوز الدم* )aimeacylgopyh(، نقص الصوديوم* )aimeartanopyh((، )اعتلال الدماغ الكبدي، تضّخم الغدة الدرقية* )msidioryhtrepyh(، السكتة الدماغية، استخدام المواد المدمنة )مثل الامفيتامينات(، تاريخ مؤكد من الذهان وتاريخ مؤكد من الصرع. » إذا تّم استبعاد الأسباب المذكورة أعلاه، التحقيق في تاريخ تعاطي الكحول بطرح الأسئلة التالية على الشخص والقائمين على العناية به: هل يشرب الشخص الكحول؟ متى تناول آخر مشروب؟ كم الكمية التي يشربها عادة؟ » إن الانقطاع عن الكحول أمر محتمل عند ظهور الأعراض بعد وقف التعاطي المنتظم للكحول أو بكميات كبيرة، عادة يوما ًإلى يومين بعد تناول آخر مشروب. إذا أُصيب الشخص بنوبات أو هلوسات ولم يُشتبه بأعراض انقطاع عن الكحول، يجب عندئذ تقييم إمكانية إصابته بالصرع )>> IPE( أو الذهان )>> YSP(. السؤال التقييمي ۲: إذا كان الشخص يعاني من انقطاع عن الكحول، فهل يشكل ذلك خطرا ًعلى حياته؟ » تقييم الأعراض التي تشكل خطرا ًعلى حياة الشخص: الاختلاجات/النوبات )عادة خلال 8٤ ساعة( علامات الهذيان* )muiriled( )عادة خلال 69 ساعة( – التّشوش الحاد، التوهان – الهلوسات. » تقييم ما إذا كان الشخص معرّضا ًبدرجة كبيرة لظهور أعراض تشكل خطرا ًعلى حياته )اختلاجات أو هذيان( في اليوم أو اليومين القادمين: أعراض سابقة شكلت خطرا ًعلى حياته )اختلاجات أو هذيان( أو أعراض انقطاع حاد حالية: – اهتياج شديد، سرعة انفعال، قلق شديد – تعرّق مفرط، رجفان اليد – ارتفاع ضغط الدم )مثلاً > 081/001 ملم زئبق( و/أو ارتفاع في معّدل ضربات القلب )مثلاً > 001 نبضة في الدقيقة(. في حال الاشتباه بهذيان ناتج عن الانقطاع عن الكحول، إطلاق خطة التدبير الطارئة للانقطاع عن الكحول الذي يشكل خطرا ًعلى الحياة (ارجع أدناه) والعمل على نقل الشخص إلى أقرب مستشفى. خطة التدبير الطارئة للانقطاع عن الكحول الذي يشكل خطرا ًعلى حياة الشخص 1. معالجة الانقطاع عن الكحول فورا ًبوصف الديازيبام (>> الجدول 1 BUS) » إن جرعة الديازيبام تعتمد على تحّمل* )ecnarelot( الشخص للديازيبام، حّدة أعراض الانقطاع ووجود اضطرابات بدنية متزامنة. تعديل الجرعة وفقا للتأثير الملحوظ. إن الجرعة الصحيحة هي تلك التي تسبّب نسبة قليلة من التخدير. – إن الجرعة العالية جدا ًيمكنها التسبّب بتخدير مفرط وبتثبيط التنفس. مراقبة معدل تنفس الشخص ومستوى التخدير )مثل النعاس( على نحو متكرر. – إن الجرعة المنخفضة جدا ًيمكنها التسبّب بنوبات/هذيان. » مراقبة أعراض الانقطاع على نحو متكرر )كل 3-٤ ساعات(. مواصلة إعطاء الديازيبام حتى زوال الأعراض )عادة لمدة ۳-٤ أيام على ألا تتعدى 7 أيام(. ٦. توفير المتابعة المنتظمة » مواصلة توفير الدعم، التباحث والعمل مع الشخص والقائمين على العناية به بشأن وقف أو التقليل من تعاطي الكحول أو مواد الإدمان. » ترتيب وإجراء جلسات متابعة منتظمة (>> مبادئ التدبير ضمن المبادئ العامة للرعاية). 05 » في حال حصول نوبة انقطاع، عدم استخدام مضادات الصرع. مواصلة إعطاء الديازيبام. » قد تستمر أعراض الهذيان كالتّشّوش أو الاهتياج أو الهلوسات بضعة أسابيع بعد زوال الأعراض الأخرى للانقطاع عن الكحول. في هذه الحال، النظر في استخدام مضادات الذهان مثل الهالوبيريدول 2،5- 5 ملغم حتى ثلاث مرات في اليوم عن طريق الفم إلى أن تتحّسن أعراض التشّوش أو الاهتياج أو الهلوسات. في بعض الحالات، قد يستغرق الأمر بضعة أسابيع قبل زوال التشّوش والهلوسات. عدم الإفراط في تخدير الشخص. » إن أمكن، ايجاد بيئة هادئة، غير محفزة، جيدة الإضاءة. محاولة توفير بعض الإضاءة في الليل أيضا ًلتفادي سقوط الشخص إذا قّرر النهوض في منتصف الليل. النظر في وضع الشخص على فراش على الأرضية لتفادي الإصابات. إن أمكن، الطلب من القائم على العناية بالشخص البقاء معه ومراقبته. تجّنب تقييد الشخص إن أمكن ذلك. ۲. معالجة سوء التغذية » إعطاء الفيتامين ب 1 )الثيامين( 001 ملغم/اليوم عن طريق الفم لمدة 5 أيام. » تقييم سوء التغذية ومعالجته. ۳. التأكد من عدم إصابة الشخص بالجفاف. » الإماهة بالوريد إن أمكن. » التأكد من حصول الشخص على السوائل عن طريق الفم )على الأقل 2-3 ليترات/اليوم(. ٤. عند انتهاء الانقطاع المهّدد للحياة، الانتقال إلى تقييم وتدبير التعاطي الضار للكحول أو مواد الإدمان (مراجعة النص الأساسي لهذه الوحدة). الجدول 1 BUS: الديازيبام لعلاج الانقطاع عن الكحول الذي يشكل خطرا ًعلى حياة الشخص الديازيبامأ 01-02 ملغم حتى ٤ مرات/اليوم لمدة 3-7 أيامالجرعة الأولية تخفيف الجرعة و/أو تواترها تدريجيا ًحالما تتحسن الأعراض. المراقبة على نحو متكرر بما أن الاستجابة لهذا الجرعة التالية الدواء تختلف بحسب الأشخاص عن طريق الفمطريقة إعطاء الدواء تثبيط التنفس* )noisserped yrotaripser( ، اختلال شديد للوعيالآثار الجانبية الخطيرة )نادرة( تحذير: مراقبة معدل التنفس ومستوى التخدير على نحو متكرر النعاس، فقدان الذاكرة، تغير في حالة الوعي، ضعف في العضلاتالآثار الجانبية الشائعة تحذير: عدم إعطاء جرعة أخرى إذا كان الشخص يشعر بالنعاس محاذير بالنسبة إلى مجموعات خاصة استخدام ربع إلى نصف الجرعة المقترحة للأشخاص المسّنين عدم وصفه للأشخاص الذين يعانون من مشاكل في التنفس 15أمتوفر في المجموعة الصحية المشتركة بين الوكالات لحالات الطوارئ )منظمة الصّحة العالمية، 1102(. الانتحار الاضطراب النفسي والضيق العاطفي الحاد والشعور باليأس كلها مشاكل شائعة في مواقع الطوارئ الإنسانية، يمكنها أن تؤدي إلى الانتحار* (edicius) أو أفعال إيذاء الذات* (mrah-fles). يخشى بعض مقّدمي الرعاية الصحية بشكل خاطئ من أن الاستفسار عن الانتحار سيدفع بالشخص إلى محاولة الانتحار. على العكس من ذلك، إن التكلم عن الانتحار يخّفف غالبا ًالقلق حيال الأفكار الانتحارية ويساعد الشخص على الإحساس بتفّهم الآخرين له ويعطيه فرصة لمناقشة مشكلته بشكل موّسع. إن البالغين والمراهقين المصابين بأي من الاضطرابات النفسية أو العصبية أو استخدام مواد الإدمان التي يغطيها هذا الدليل مع رضون لخطر الانتحار أو إيذاء الذات. الشكاوى النموذجية لشخص معرض لخطر الانتحار أو إيذاء الذات الشعور بالضيق أو الكآبة الشديدين شعور عميق باليأس أو الحزن محاولات سابقة لإيذاء الذات (مثل التسّمم الحاد بالمبيدات، الجرعة الزائدة من الأدوية، إصابة ألحقها الشخص بنفسه). 25 التقييم السؤال التقييمي 1: هل أقدم الشخص مؤخرا ًعلى محاولة الانتحار أو إيذاء الذات؟ السؤال التقييمي ۲: هل هناك خطر وشيك بالإقدام على الانتحار أو إيذاء الذات؟ السؤال التقييمي ۳: هل يعاني الشخص من حالات مرضّية متزامنة مرتبطة بالانتحار أو إيذاء الذات؟ » تقييم ما يلي: التسّمم، التسّمم بالكحول/مواد الإدمان، الجرعة الزائدة من الأدوية أو غيرها من أفعال إيذاء الذات علامات تتطلب المعالجة الطبية العاجلة – نزيف من إصابة ألحقها الشخص بنفسه – فقدان الوعي – خمول شدي » سؤال الشخص و/أو القائمين على العناية به عن: أفكار أو خطط انتحار )حالية أو خلال الشهر الماضي( أفعال إيذاء الذات خلال العام الماضي سهولة الوصول إلى وسائل الانتحار )مثل المبيدات، الحبل، الأسلحة، السكاكين، الأدوية الموصوفة والمواد المدمنة(. » البحث عن: ضيق عاطفي شديد أو شعور باليأس سلوك عنيف أو هياج حاد علامات انسحاب أو رفض التواصل » يعتبر الشخص معرّضا ًلخطر وشيك بالإقدام على الانتحار أو إيذاء الذات في حال توفر أي من النقاط التالية: أفكار، خطط أو أفعال انتحار حالية تاريخ من أفكار أو خطط إيذاء الذات خلال الشهر الماضي أو القيام فعليا ًبإيذاء الذات خلال العام الماضي لدى شخص يعاني الآن من حالة شديدة من الضيق أو السلوك العنيف أو الهياج أو صعوبة التواصل. » تقييم وتدبير الحالات المرضيّة المتزامنة المحتملة: ألم مزمن أو إعاقة )على سبيل المثال، ناجمة عن إصابة حديثة ناجمة عن حالة الطوارئ الإنسانية( الاضطراب الاكتئابي المعتدل إلى الحاد )>> PED( الذهان )>> YSP( التعاطي الضار للكحول أو مواد الإدمان )>> BUS( اضطراب الكرب ما بعد الصدمة )>> DSTP( الضيق العاطفي الحاد )>> UCA ,IRG ,HTO( المربع 1 IUS : كيفية التحدث عن الانتحار أو إيذاء الذات 1. إيجاد بيئة آمنة تراعي خصوصّية الشخص يعّبر فيها عن أفكاره. » اقتراح التحدث مع الشخص على انفراد أو برفقة أشخاص آخرين » عدم إصدار الأحكام بسبب ميول الشخص الانتحارية. من اختياره. ۲. استخدام مجموعة من الأسئلة حيث كل إجابة تؤدي تلقائيا ًإلى سؤال آخر. على سبيل المثال: » [البدء بالوقت الحاضر] كيف تشعر؟ » [التنويه بمشاعر الشخص] تبدو حزينا/ًكئيبا.ً أود أن أطرح عليك بعض الأسئلة بهذا الخصوص. » كيف ترى مستقبلك؟ ما هي تطلعاتك المستقبلية؟ » لقد قال لي بعض الأشخاص الذين يعانون من مشاكل مماثلة أنهم يشعرون بأن الحياة لا تستحق العيش. هل تذهب إلى الفراش ليلاً متمّنيا ًعدم الاستيقاظ في الصباح؟ » هل تفكر بإيذاء نفسك؟ » هل وضعت خططا لإنهاء حياتك؟ » في حال الإيجاب، كيف تنوي القيام بذلك؟ » هل لديك الوسائل لإنهاء حياتك؟ » هل فكرت متى ستقوم بالأمر؟ » هل أقدمت يوما على محاولة الانتحار؟ ۳. إذا عّبر الشخص عن أفكار انتحارية: 35» عدم إعطاء وعود كاذبة.» الالتزام بموقف هادئ وداعم خطة التدبير الأساسية 1. إذا أقدم الشخص فعلا ًعلى محاولة انتحار، توفير الرعاية الطبية الضرورية والمراقبة والدعم النفسي الاجتماعي ۲. إذا كان الشخص معرّضا ًلخطر وشيك بالإقدام على الانتحار أو إيذاء الذات، مراقبته وتوفير الدعم النفسي الاجتماعي ٤. التواصل مع الشخص ومتابعته بشكل منتظم ۳. توفير الرعاية للقائمين على العناية بالشخص كما هو موصوف في مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية) » توفير الرعاية الطبية: للأشخاص الذين أقدموا على إيذاء أنفسهم توفير نفس الرعاية والاحترام والخصوصيّة كما لآخرين. عدم معاقبتهم. معالجة الإصابة أو التسّمم. – للتسّمم الحاد بالمبيدات، مراجعة المعالجة السريرية للتسّمم الحاد بالمبيدات)منظمة الصّحة العالمية، 8002( في حال حصول جرعة زائدة من دواء موصوف لا يزال استخدامه ضروريا،ً اختيار الدواء البديل الأقل ضررا.ً إن أمكن، وصف الدواء الجديد لفترات قصيرة فقط )كبضعة أيام إلى أسبوع في كل مرة( لتجّنب جرعة زائدة أخرى. » مراقبة الشخص باستمرار ما دام معرّضا ًلخطر وشيك بالإقدام على الانتحار )من أجل المزيد من التوجيهات، راجع أدناه(. » توفير الدعم النفسي الاجتماعي )من أجل المزيد من التوجيهات، راجع أدناه(. » استشارة أخصائي صحة نفسية إن وجد. » مراقبة الشخص: إيجاد بيئة آمنة وداعمة للشخص. إزالة كافة وسائل الانتحار/إيذاء الذات وإن أمكن توفير غرفة هادئة مستقلة. في كل الأحوال، عدم ترك الشخص بمفرده. الطلب من القائمين على العناية به أو الموظفين البقاء معه في كافة الأوقات. عدم استقبال الأشخاص بصورة روتينية في أجنحة الطب العام بهدف حمايتهم من الإقدام على الانتحار، فلعّل موظفي المستشفى غير قادرين على مراقبة شخص ذي ميول انتحارية بشكل فّعال. ولكن إن كان لا بّد من إدخال شخص إلى الجناح العام لمعالجة العواقب الطبية لفعل إيذاء الذات، يجب عندها مراقبته عن كثب لمنعه من الإقدام على إيذاء نفسه في المستشفى. بغض النظر عن الموقع، ضمان مراقبة الشخص ٤۲ ساعة في اليوم حتى زوال الخطر الوشيك بالانتحار. » توفير الدعم النفسي الاجتماعي: عدم البدء بتقديم الحلول الممكنة لمشاكل الشخص. عوضا ًمن ذلك، محاولة زرع الأمل. على سبيل المثال: – أشخاص كثيرون مّروا في ظروف مماثلة – شعور باليأس، رغبة في الموت – اكتشفوا لاحقا ًأن الأمل لم يزل قائما ًفتحّسنت مشاعرهم مع الوقت. مساعدة الشخص على استكشاف أسباب تجعله يتعلق بالحياة. البحث مع الشخص عن حلول لمشاكله. تعبئة القائمين على العناية بالشخص، الأصدقاء، أفراد موثوقين آخرين والموارد المجتمعية من أجل مراقبة الشخص ودعمه إن كان معرّضا ًلخطر وشيك بالانتحار. شرح الحاجة لمراقبة الشخص ٤۲ ساعة في اليوم. التأكد من وضعهم خطة ملموسة وُمجدية )على سبيل المثال، من يراقب الشخص وفي أي وقت من اليوم(. توفير الدعم النفسي الاجتماعي الإضافي كما هو موصوف في مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية). » استشارة أخصائي صحة نفسية إن وجد. » التأكد من أن تتوفر خطة ملموسة لجلسات المتابعة وأن يتحّمل القائمون على العناية بالشخص مسؤولية ضمان المتابعة )>> مبادئ التدبير ضمن المبادئ العامة للرعاية(. » البقاء على تواصل منتظم مع الشخص )عن طريق الهاتف أو الرسائل النصية أو الزيارات المنزلية(. » في البدء، المتابعة على نحو متكرر )على سبيل المثال، أسبوعيا ًفي الشهرين الأّولين( وعلى فترات متباعدة مع تحّسن حال الشخص )مرة كل أسبوعين إلى أربعة أسابيع(. » متابعة الشخص ما دام خطر الانتحار قائما.ً وفي كل مقابلة، إجراء تقييم روتيني للأفكار والخطط الانتحارية. 45 شكاوى الصحة النفسية الهامة الأخرى على الرغم من أن هذا الدليل يغطي الاضطرابات النفسية والعصبية واستخدام مواد الإدمان الرئيسية المرتبطة بمواقع الطوارئ الإنسانية، إلا أنه لا يغطي كافة اضطرابات الصحة النفسية الممكن حصولها. لذا، تهدف هذه الوحدة لتوفير التوجيهات الأساسية بشأن الدعم المبدئي للبالغين والمراهقين والأطفال الذين يعانون من مشاكل نفسية لم تتم تغطيتها في وحدات أخرى من هذا الدليل. تشمل شكاوى الصحة النفسية الأخرى ما يلي: (أ) أعراض بدنية مختلفة ما من مسّببات بدنية لها (ب) والتقلبات المقلقة في المزاج والسلوك التي لا تنطبق بشكل قاطع مع معايير الحالات التي تمّت تغطيتها في وحدات أخرى من هذا الدليل. وقد تضّم الشكاوى التي تّتسم باضطراب اكتئابي خفيف ومجموعة من الحالات دون السريرية. تعتبر شكاوى الصحة النفسية الأخرى هامة عندما تعيق الأداء اليومي للشخص أو عندما يسعى الشخص للحصول على المساعدة بسببها. 55 التقييم السؤال التقييمي 1: هل من سبب بدني يفسر بشكل قاطع الأعراض القائمة؟ السؤال التقييمي ۲: هل هو اضطراب نفسي أو عصبي أو استخدام مواد إدمان تّمت مناقشته في وحدة أخرى من هذا الدليل؟ السؤال التقييمي ۳: إذا كان الشخص مراهقا،ً فهل يعاني من مشكلة سلوكية؟ » معالجة أّي سبب بدني تّم استكشافه وإعادة التحقق مّما إذا كانت » إجراء فحص بدني عام وفحوص طبية لاحقة مناسبة. الأعراض مستمرة. » استبعاد: الأعراض الشديدة للكرب الحاد (>> UCA) – السمات الرئيسية حدث قادر على التسبّب بصدمة حصل في الشهر الماضي بدأت الأعراض بعد الحدث السعي للحصول على المساعدة لتخفيف الأعراض أو صعوبة هائلة في الأداء اليومي بسبب الأعراض. الأعراض الشديدة للحزن (>> IRG) – السمات الرئيسية خسارة كبيرة بدأت الأعراض بعد الخسارة السعي للحصول على المساعدة لتخفيف الأعراض أو صعوبة هائلة في الأداء اليومي بسبب الأعراض الاضطراب الاكتئابي المعتدل إلى الحاد (>> PED) – السمات الرئيسية )لمدة أسبوعين على الأقل( مزاج مكتئب مستمر تدٍن ملحوظ للاهتمام أو الاستمتاع بالأنشطة التي كانت في السابق ممتعة صعوبة هائلة في الأداء اليومي بسبب الأعراض. اضطراب الكرب ما بعد الصدمة (>> DSTP) – السمات الرئيسية حدث قادر على التسبّب بصدمة حصل منذ أكثر من شهر كوابيس متكررة، ارتجاع* )kcabhsafl( أو ذكريات اقتحامية* )seiromem evisurtni( للحدث، يرافقها شعور بالخوف الشديد أو الرعب تجّنب متعّمد لما يذكّر الشخص بالحدث إحساس متصاعد بالخطر الراهن )تخّوف شديد وتيّقظ للخطر أو إصدار ردود فعل قوية على الأصوات الصاخبة أو الحركات غير المتوقعة( صعوبة هائلة في الأداء اليومي بسبب الأعراض. التعاطي الضار للكحول أو مواد الإدمان (>> BUS) – السمة الرئيسية تعاطي الكحول أو مواد الإدمان التي تلحق الأذى بالنفس و/أو بالآخرين. الانتحار/إيذاء الذات (>> IUS) – السمات الرئيسية أفعال إيذاء ذات حالية؛ أفكار وخطط انتحارية حالية أو أفكار وخطط وأفعال إيذاء الذات لدى شخص يعاني من حالة شديدة من الضيق أو الهياج أو صعوبة التواصل أو الانسحاب. » في حال الاشتباه بأحد الاضطرابات المذكورة أعلاه، الانتقال إلى الوحدة المناسبة بهدف التقييم والتدبير. » إذا 1) تّم استبعاد الأسباب البدنية، ۲) تّم استبعاد الاضطرابات النفسية والعصبية واستخدام مواد الإدمان المذكورة أعلاه و ۳) كان الشخص يسعى للحصول على المساعدة بهدف تخفيف الأعراض أو يعاني من صعوبات هائلة في الأداء اليومي بسبب الأعراض، تكون لديه عندئذ شكوى هامة أخرى تتعلق بالصحة النفسية. إن استبعاد الأسباب البدنية والاضطرابات النفسية والعصبية واستخدام مواد الإدمان المذكورة أعلاه يحتاج عادة إلى أكثر من مقابلة واحدة. » مقابلة المراهق والقائمين على العناية به على السواء بهدف تقييم ما إذا كانت هناك مشاكل سلوكية مستمرة أو مقلقة. الأمثلة هي التالية: سلوك عنيف استخدام المواد المسبّبة للإدمان التنّمر أو القسوة تجاه الأنداد الأعمال التخريبية السلوك الجنسي المتهّور. » إذا كان المراهق يعاني فعلاً من مشكلة سلوكية، طرح الاسئلة الإضافية حول: الضغوطات الشديدة في المرحلة السابقة أو الحالية من حياة المراهق )مثل الاعتداء الجنسي( مهارات الأبوة )تأديب متباين أو صارم جدا،ً دعم عاطفي محدود، مراقبة محدودة، حالة نفسية لدى القائم على العناية بالمراهق( كيفية قضاء المراهق معظم وقته. السؤال: – )إذا كان المراهق يعمل أو يذهب إلى المدرسة(. كيف تقضي وقتك بعد المدرسة/العمل؟ هل تمارس أنشطة منتظمة؟ 65– هل تشعر بالملل في أحيان كثيرة؟ ماذا تفعل حينما تشعر بالملل؟ خطة التدبير الأساسية » التعامل مع الضغوطات النفسية الاجتماعية الحالية » تعزيز الدعم الاجتماعي » تعليم كيفية التعامل مع الضغط النفسي » عدم طلب المزيد من الفحوص المخبرية أو غيرها من الفحوص الا إذا كانت هناك حاجة طبية واضحة لها )كالعلامات الحياتية غير الطبيعية(. إن طلب الفحوص السريرية غير الضرورية قد يرسخ اعتقاد الشخص بوجود مشكلة بدنية. للفحوص السريرية آثار جانبية سلبية محتملة. » إخبار الشخص بأنه لا يعاني من مرض خطير وإبلاغه النتائج السليمة للفحوص السريرية والفحوص الأخرى. لم نجد أي مشكلة بدنية خطيرة. لا نرى حاجة لإجراء المزيد من الفحوص في الوقت الحالي. » إن أّصر الشخص على إجراء المزيد من الفحوص، إجابته بالقول: إن إجراء فحوص غير ضرورية قد يكون مضرا ًلأنها تسّبب قلقا ً وآثار جانبية لا فائدة منها. » التسليم بأن الأعراض لا يتخيلها الشخص وأنه لا يزال من الضروري علاج الأعراض المسبّبة للضيق الشديد. » الطلب من الشخص أن يشرح سبب الأعراض بحسب اعتقاده، فقد يعطينا ذلك فكرة عن السبب، ويساعد في بناء علاقة ثقة مع الشخص ويضاعف التزامه بالعلاج. » الشرح للشخص بأن الضيق العاطفي/التوتر يرتبطان بالأحاسيس الجسدية )ألم في المعدة، توتر في العضلات(. سؤاله عن الصلات المحتملة بين مشاعره/توتره والأعراض ومناقشتها. » تشجيع الشخص على مواصلة الأنشطة اليومية )أو العودة لها تدريجيا(ً. » تذكر أيضا ًتطبيق مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية). » تخصيص الوقت اللازم للاستماع إلى المراهق عن تصّوره الخاص للمشكلة )من الأفضل القيام بذلك في غياب القائمين على العناية به(. » توفير التثقيف النفسي للمراهق والقائمين على العناية به. شرح ما يلي: يبدي المراهقون أحيانا ًسلوكا ًشاذا ًعندما يتملكهم شعور بالغضب أو الملل أو القلق أو الحزن. هم بحاجة للرعاية والدعم المستمرين بغض النظر عن سلوكهم. يجب أن يبذل القائمون على العناية بالمراهقين أقصى الجهود للتواصل معهم على الرغم من صعوبة الأمر. رسائل خاصة بالقائمين على العناية بالمراهقين: – محاولة تحديد أنشطة ممتعة إيجابية يمكنهم القيام بها معا.ً – عدم التساهل بشأن ما هو مسموح وغير مسموح للمراهق القيام به.– مدح المراهق أو مكافأته لسلوكه الحسن وتصحيح السلوك الأكثر شذوذا ًفقط. – عدم استخدام العقاب الجسدي أبدا.ً تفضيل مدح السلوك الحسن على معاقبة السلوك الشاذ. – عدم مواجهة المراهق حينما تكون مستاًء جدا.ً التريّث لحين أن تهدأ. نقاط محّددة تجدر مناقشتها مع المراهق: – تتوفر طرق سليمة للتعامل مع الملل أو التوتّر أو الغضب )مثل القيام بأنشطة تساعد على الاسترخاء، ممارسة نشاط بدني، الانشغال بأنشطة مجتمعية(. – من المجدي التحدث مع أشخاص موثوقين حول الشعور بالغضب أو الملل أو القلق أو الحزن. – إن شرب الكحول واستخدام مواد الإدمان الأخرى يزيدان مشاعر الغضب والاكتئاب سوءا،ً لذا يجب تجّنبها. » تعزيز المشاركة في: التعليم الرسمي وغير الرسمي الأنشطة ذات الفائدة المشتركة الهادفة والملموسة )كبناء المآوي( البرامج الرياضية المنهجية. » تذكر أيضا ًتطبيق مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية) على هذه المجموعة من المراهقين والقائمين على العناية بهم. ۲. إذا لم يتم استكشاف حالة بدنية تفسر بشكل قاطع العارض البدني القائم، التسليم بحقيقة الأعراض وتقديم التفسيرات الممكنة ۳. إذا كان الشخص مراهقا ًيعاني من مشاكل سلوكية 1. في كافة الأحوال (إن كان الشخص يعاني من مشاكل عاطفية أو بدنية أو سلوكية)، توفير الدعم النفسي الاجتماعي الأساسي كما هو موصوف في مبادئ تقليص الضغط النفسي وتعزيز الدعم الاجتماعي (>> المبادئ العامة للرعاية). عدم وصف الأدوية لـ "شكاوى الصحة النفسية الهامة الأخرى" )إلا بنصيحة طبيب متخّصص(. عدم إعطاء حقن الفيتامين أو غيرها من العلاجات غير الفّعالة. 75 ٤. المتابع » إذا استمرت الأعراض أو ازدادت سوءا ًأو أصبحت غير محتملة، الطلب من الشخص العودة. » إذا لم يلحظ أي تحسن أو أّصر الشخص أو القائم على العناية به على إجراء المزيد من الفحوص وتكثيف العلاج، استشارة أخصائي. الملحق 1: تعريف الحالات لنظام المعلومات الصحية (SIH) للمفوضية السامية للأمم المتحدة لشؤون اللاجئين (٤102) 1. الصرع/النوبات إن الشخص المصاب بالصرع يتعرّض لنوبتين على الأقل لا سبب ظاهر لهما كالحمى أو العدوى أو الإصابة أو الانقطاع عن الكحول. تتميز هذه النوبات بفقدان للوعي يصحبه اهتزاز للأطراف ويرتبط في بعض الأحيان بالإصابات الجسدية، سلس البول أو البراز وعض اللسان. ۲. اضطراب تعاطي الكحول أو غيرها من مواد الإدمان يعمد الشخص المصاب بهذا الإضطراب إلى استهلاك الكحول أو غيرها من المواد المسبّبة للإدمان ويواجه صعوبة في ضبط استهلاكه، مّما يتسبّب غالبا ًفي تدهور العلاقات الشخصية والأداء المهني والصحة الجسدية. وعلى الرغم من تلك المشاكل، يواصل الشخص استهلاك الكحول أو غيرها من المواد المسبّبة للإدمان. ۳. التأخر العقلي يكون مستوى الذكاء لدى الشخص متدنيا ًجدا ًمّما يتسبّب بمشاكل في حياته اليومية. ففي مرحلة الطفولة، يعاني هذا الشخص من بطء في تعلم الكلام. وفي مرحلة الرشد، لا يتمكن من إنجاز سوى الأعمال البسيطة. ونادرا ًما يتمكن من العيش باستقلالية أو الاعتناء بنفسه و/أو بمُعاليه من دون مساعدة الآخرين. وفي حالات الإعاقة الحاّدة، قد يعاني الشخص من صعوبات في التكلم مع الآخرين وفهمهم وقد يحتاج إلى مساعدة دائمة. ٤. الاضطراب الذهاني (بما في ذلك الهوس) قد يسمع الشخص أو يرى أشياء ليست موجودة، أو يصدق أمورا ًبشدة فيما هي غير صحيحة في الواقع. ومن الممكن أن يكلم هذا الشخص نفسه، وأن يكون كلامه مشّوشا ًأو غير مترابط، كما قد يظهر بمظهر غير اعتيادي أو يهمل نفسه. وفي المقابل، قد يعيش هذا الشخص فترات يكون خلالها سعيدا للغاية، سريع الانفعال، نشيطا،ً ثرثارا ًومتهورا.ً ويعتبر سلوك الشخص "مجنونا"ً/غريبا ًجدا ًمن قبل الأشخاص الآخرين من الثقافة نفسها. وتضم هذه الفئة الذهان الحاد، الذهان المزمن، الهوس والهذيان. 5. الاضطراب العاطفي المعتدل إلى الحاد/الاكتئاب يضعف الأداء اليومي العادي للشخص بشكل واضح لأكثر من أسبوعين من جراء )أ( حزن شديد/لامبالاة و/أو )ب( قلق/خوف مبالغ فيه خارج عن السيطرة. وغالبا ما يؤثر هذا الاضطراب في العلاقات الشخصية والشهية والنوم والتركيز. كما قد يشتكي الشخص من تعب شديد وينعزل اجتماعيا،ً بحيث يلازم السرير معظم النهار. ويعّد التفكير في الانتحار أم شائعا.ً تضم هذه الفئة الأشخاص الذين يعانون من أشكال ُمعيقة من الاكتئاب واضطرابات القلق واضطراب الكرب ما بعد الصدمة )الذي يتّسم بعيش التجربة من جديد والتجّنب وفرط التيقظ(. إن الأشكال الأخف من هذه الاضطرابات مصّنفة تحت عنوان "الشكاوى النفسية الأخرى". ٦. الشكاوى النفسية الأخرى تغطي هذه الفئة الشكاوى ذات الصلة بالمشاعر )مثل المزاج المكتئب، القلق( أو الأفكار )مثل اجتارار الأفكار، ضعف التركيز( أو السلوك )مثل الخمول والعدائية والتجّنب(. ويميل الشخص إلى أن يكون قادرا ًعلى تأدية معظم الأنشطة اليومية العادية. وقد تمثل الشكوى عارضا ًمن أعراض اضطراب عاطفي أقل حدة )كالأشكال الأقل حدة من الاكتئاب أو اضطراب القلق أو اضطراب الكرب ما بعد الصدمة( أو ربما تكون ضيقا ًعاديا ً)أي أنه ليس اضطرابا(ً. معايير الإدراج: يجب ألا تطبق هذه الفئة إلا )أ( في حال طلب الشخص المساعدة بسبب الشكوى، و)ب( إذا كانت حالة الشخص لا تنطبق بشكل قاطع على أي من الفئات الخمس السابقة. ٧. الشكاوى الجسدية غير المفسرة طبياً تشمل هذه الفئة أي شكوى جسدية ليس لها أي سبب عضوي واضح. معايير الإدراج: يجب ألا تطبق هذه الفئة إلا )أ( بعد إجراء الفحوص الجسدية اللازمة، )ب( إذا كانت حالة الشخص لا تنطبق بشكل قاطع على أي من الفئات الست السابقة، و)ج( في حال طلب الشخص المساعدة بسبب الشكوى. 85 الملحق ۲: قائمة المصطلحات 01 11 الآثار الجانبية خارج الهرمية edis ladimarypartxE stceffe إنها شذوذ في حركة العضلات، ناتج في الغالب عن الأدوية المضادة للذهان. وهي تشمل الرعاش، التصلّب، التشّنج العضلي و/أو تعّذر الجلوس. أي أن يعتقد الشخص ويتصرف لبعض الوقت كما لو أنه عاد إلى زمن حصول kcabhsalFالارتجاع الحدث فيعيشه من جديد. في حال الارتجاع، يفقد الأشخاص الاتصال بواقعهم لوقت وجيز، عادة لبضعة ثوان أو دقائق. gnivlos-melborPالإرشاد بحل المشاكل gnillesnuoc إنه علاج نفسي قائم على الاستخدام المنهجي لتقنيات تحديد المشاكل وحلّها في عدد من الجلسات. إزالة حساسية حركة العين واعادة المعالجة tnemevom eyE dna noitazitisnesed (RDME) gnissecorper إنها علاج نفسي يستند إلى فكرة أن السلوك والأفكار والمشاعر السلبية وليدة الذكريات غير المُعالجة لأحداث صادمة. ينطوي هذا العلاج على إجراءات موّحدة تنص على التركيز في آن واحد على )أ( مجموعات مترابطة من الصور والأفكار والمشاعر والأحاسيس الجسدية المؤلمة و)ب( التحفيز الثنائي الذي هو غالبا ًفي شكل حركات متكررة للعينين. إنه تجّمع غير طبيعي للسوائل في البطن، له أسباب متنوعة.seticsAاستسقاء البطن إنها مجموعة من الهرمونات المتوفرة في شكل دواء، لها وظائف هامة بما sdioretSالاستيرويدات في ذلك إيقاف الاستجابة الالتهابية لعدوى وسموم وغيرها من الاضطرابات المتعلقة بالمناعة. الأمثلة عن الأدوية الاستيرويدية تشمل القشرانية السكرية )كالبريدنيزولون( وموانع الحمل الهرمونية. الإسعافات النفسية الأولية tsrfi lacigolohcysP (AFP) dia توفّر الرعاية الداعمة للأشخاص الذين يمّرون بحال من الضيق بعد تعرّضهم مؤخرا ًلأزمة. تشمل الرعاية تقييم الحاجات الملّحة للشخص ومخاوفه؛ ضمان تلبية احتياجاته البدنية الأساسية الملّحة؛ توفير أو تعبئة الدعم الاجتماعي؛ وحمايته من المزيد من الأذى. cilobateM الاضطراب الاستقلابي ytilamronba إنه اختلال في هرمونات، معادن، كهارل أو فيتامينات الجسم. إنه اضطراب نفسي حاد يتّسم بتناوب نوبات الهوس ونوبات الاكتئاب.redrosid ralopiBالاضطراب ثنائي القطب إعادة التأهيل المجتمعية desab-ytinummoC (RBC) noitatilibaher إنها كناية عن مجموعة من التدخلات المُسداة داخل البيئات المجتمعية، من خلال استراتيجية متعددة القطاعات تستخدم الموارد والمؤسسات المجتمعية المتاحة ضمن هذه البيئات. وهي تهدف إلى إعادة التأهيل بتحسين نوعية حياة الأشخاص المصابين بإعاقات وحياة أسرهم، وتلبية حاجاتهم الأساسية وضمان اندماجهم ومشاركتهم في المجتمع. 01 إن مصطلحات القائمة تقترن في النص بعلامة *. 11 إن التعريفات الإجرائية الواردة في هذه القائمة يجب استخدامها فقط في نطاق دليل التدخلات الإنسانية لبرنامج رأب الفجوة في الصّحة النفسية )GIH-PAGhm(: المعالجة السريرية للاضطرابات النفسية والعصبية واستخدام مواد الإدمان في حالات الطوارئ الإنسانية )منظمة الصحة العالمية والمفوضية السامية للأمم المتحدة لشؤون اللاجئين، 5102(. 95 yhtapolahpecne citapeHاعتلال الدماغ الكبدي إنه حالة نفسية غير طبيعية تشمل الخمول أو التشّوش أو الغيبوبة، سببها خلل الكبد الوظيفي. إن اعتماد الأشخاص على مادة )مواد الإدمان أو الكحول أو التبغ( يشير إلى الحالة التي ecnednepeDالاعتماد يُصاب فيها الأشخاص بأعراض معرفية وسلوكية وجسدية مزعجة في غياب هذه المادة. تدفعهم أعراض الانقطاع لأن يسعوا لاستهلاك المزيد من هذه المادة لأنهم غير قادرين على ضبط استهلاكهم للمادة ويستمرون في ذلك على الرغم من عواقبها السلبية. إنه مادة مخّدرة مستمّدة من خشخاش الأفيون. تشكل المواد الأفيونية مسكنات ألم etaipOالأفيون فعالة جدا ًولكنها قد تسبّب الادمان والاعتماد. الهيروين مخّدر أفيوني. laegnineMتهيّج السحايا noitatirri إنه تهيّج طبقات الأنسجة التي تغطي الدماغ والنخاع الشوكي، ناجم عادة عن التهاب. إنه التهاب يطال الدماغ و/أو النخاع الشوكي.noitcefniorueNالالتهاب العصبي إنها مجموعة من الأدوية لها تأثير منشط على الجهاز العصبي المركزي، يمكنها مضاعفة senimatehpmAالامفيتامينات التنبّه الذهني والشعور باليقظة. يمكن استخدامها كعلاج أساسي لبعض الاضطرابات الصحية ولكنها أيضا ًمواد يمكن إساءة استخدامها تسبّب الهلوسات والاكتئاب والتأثيرات على الجهاز القلبي الوعائي. إنه حالة مرضيّة تهّدد حياة الشخص، سببها التهاب شديد. تكون هذه الحالة مصحوبة sispeSالإنتان بعلامات كالحمى واختلال الدورة الدموية واختلال الأعضاء الوظيفي. إنه إنتان ناجم عن التهاب المسالك البولية.sispesorUالإنتان البولي إنه فعل قتل النفس عمدا.ًediciuSالانتحار انخفاض ضغط الدم أثناء الوقوف citatsohtrO noisnetopyh إنه انخفاض مفاجئ لضغط الدم يمكن حدوثه عندما يغير الشخص وضعيته من الاستلقاء إلى الجلوس أو الوقوف، مسبّبا ًعادة دوخة أو دوارا.ً وهو لا يشكل خطرا ً على حياة الانسان. إنه تسميم النفس أو التسبّب بإصابة النفس، قد يكون أو لا يكون له نيّة أو نتيجة mrah-fleSإيذاء الذات قاتلة. إنها فئة من الأدوية ذات مفعول مهدئ )باعث على النوم(، مضاد للقلق، مضاد senipezaidozneBالبنزوديازيبين للتشنج ومرٍخ للعضلات. yrotaripseR تثبيط التنفس noisserped إنه معدل تنفس بطيء غير ملائم يسبّب نقصا ًفي الاكسجين، من أسبابه الشائعة إصابة في الدماغ والتسّمم )مثل التسّمم بالبنزوديازيبين(. إنه تدٍن لتأثير دواء عند استخدام الجرعة نفسها منه، ناتج عن اعتياد الجسم على ecnareloTالتحّمل الدواء بسبب الاستهلاك المتكرر. يحتاج الشخص عندها لجرعات أعلى من أجل الحصول على التأثير نفسه. إنه مادة أفيونية توصف لتخفيف الألم، يمكن إساءة استخدامها حيث أنها تثير شعورا ًlodamarTترامادول بالنشوة )يكون الشخص "منتشيا ً" أو سعيدا(ً. إنه حالة تنتج وتفرز فيها الغدة الدرقية كميات كبيرة جدا من الهرمونات الدرقية. msidioryhtrepyHتضّخم الغدة الدرقية يمكن الخلط بين بعض من أعراضها كالهذيان والرعاش وارتفاع ضغط الدم وارتفاع معدل ضربات القلب وبين أعراض الانقطاع عن الكحول. 06 إنه تناول ذاتي للكحول أو مواد الإدمان )بما في ذلك، الأدوية الموصوفة( يهدف إلى gnitacidem-fleSالتطبيب الذاتي تقليص المشاكل البدنية أو النفسية من دون استشارة طبيب مختص. إنه شعور داخلي بالتململ، تصحبه غالبا ًحركة مفرطة ملحوظة )مثل حركات تململ aisihtakAتعّذر الجلوس الساقين، التأرجح من قدم إلى أخرى، المشي بخطوات سريعة، عدم القدرة على الجلوس أو الوقوف من دون حركة(. gurd-gurDتفاعل الدواء مع الدواء noitcaretni أي أن يتفاعل دواءان يتناولهما الشخص نفسه معا،ً مّما يغير في تأثير أحد الدواءين أو كليهما. وقد تشمل التفاعلات تخفيف تأثير دواء، تقوية أو تسريع تأثير، أو إنتاج تأثير سام. esaesid-gurDتفاعل المرض مع الدواء noitcaretni أي أن يؤثر دواء موصوف لعلاج حالة صحية في حالة صحية أخرى يعاني منها الشخص نفسه. تقشر الأنسجة المتموتة البشروية التسّممي lamredipe cixoT sisylorcen إنه تقشر للجلد يشكل خطرا ًعلى حياة الشخص، ناجم عادة عن تفاعل مع دواء أو التهاب. وهو شبيه بمتلازمة ستيفنز جونسون ولكنه أكثر حّدة. gnivlos-melborPتقنيات حل المشاكل seuqinhcet إنها تقنيات تشمل العمل مع الشخص على استثارة أفكاره من أجل إيجاد الحلول واستراتيجيات التأقلم مع المشاكل التي تم تحديدها، منحها الأولوية ومناقشة كيفية تنفيذ هذه الحلول والاستراتيجيات. في دليل برنامج رأب الفجوة في الصحة النفسية، تستعمل عبارة "الإرشاد بحل المشاكل" عند استخدام هذه التقنيات بشكل منهجي في عدد من الجلسات. laruoivaheBالتنشيط السلوكي noitavitca إنه علاج نفسي يركز على تحسين المزاج من خلال استئناف الأنشطة )في شكل مهام( التي كانت في السابق ممتعة، على الرغم من انخفاض مزاج الشخص حاليا.ً يمكن استخدامه كعلاج قائم بحّد ذاته وهو أيضا َجزء من العلاج السلوكي المعرفي. إنه الأسلوب الذي يلتفت به الشخص المفجوع إلى الشخص المتوفي، موّد عا إياه gninruoMالحداد ومخلدا ًذكراه، ّسرا ًوعلانية. في الحداد، تمارس عادة الشعائر كإقامة المآتم وتحترم التقاليد كتغيير الثياب والبقاء في المنزل والصوم. حدث قادر على التسبّب بصدمة yllaitnetoP citamuart tneve إنه أي حدث مرّوع أو مهّدد للحياة كعنف جسدي أو جنسي، مشاهدة أعمال وحشية، تدمير منزل الشخص أو أية إصابات أو حوادث كبرى. أما اختبار الشخص لهذه الأنواع من الأحداث على أنها صادمة أو لا فيعتمد على استجابته العاطفية. الحدقتان المتوّسعتان/ المنقبضتان /detaliD slipup detcirtsnoc الحدقة )الجزء الأسود من العين( هي فتحة في وسط القزحية تنظم كمية الضوء الداخل إلى العين. تنقبض الحدقتان عادة في الضوء لحماية الجزء الخلفي من العين وتتوّسعان في الظلام للسماح بدخول كمية قصوى من الضوء إلى العين. إن توّسع أو انقباض الحدقتين قد يشير إلى أن الشخص تحت تأثير مواد مدمنة. evisurtnI الذكريات الاقتحامية seiromem إنها ذكريات أليمة متكررة غير مرغوب بها لحدث صادم. إنه اهتززا أو رجفان، عادة لأصابع اليدين.romerTالرعاش evissergeR السلوك التراجعي ruoivaheb إنه سلوك لا يتناسب مع السن الفعلي لنمو الطفل بل ينطبق على من هم أصغر سنا.ً من الأمثلة الشائعة: التبول اللاإرادي والتعلق الزائد لدى الأطفال. إنه اضطراب للقدرات الحركية والذهنية سببه تّضرر مبكر ودائم للدماغ في طور النمو.yslap larbereCالشلل الدماغي 16 yllacideMالشلل غير المفسر طبيا ً denialpxenu sisylarap إنه فقدان جزئي أو تام للقوة في أي جزء من البدن، لا سبب عضوي واضح له. إنها الحالة التي تنهار فيها الدورة الدموية للشخص نتيجة عدوى أو سموم أخرى kcohSالصدمة حيث قد ينخفض ضغط الدم إلى مستوى لا يتيح للشخص البقاء على قيد الحياة. أما علامات هذه الحالة فتشمل ضغط دم منخفض أو غير محسوس، بشرة باردة، غياب أو ضعف النبض، ضيق تنفس واختلال مستوى الوعي. evitingoCالعلاج السلوكي المعرفي laruoivaheb (TBC) ypareht إنه علاج نفسي يجمع بين المكونات المعرفية )التي تحث الشخص على التفكير بشكل مختلف، مثلاً من خلال تحديد ومواجهة الأفكار السلبية غير الواقعية( والمكونات السلوكية )التي تحث الشخص على التصرف بشكل مختلف، مثلاً بمساعدة الشخص على ممارسة عدد أكبر من الأنشطة المجزية(. العلاج السلوكي المعرفي المركز على الصدمة evitingoC laruoivaheb a htiw ypareht sucof amuart (T-TBC) إنه علاج نفسي يستند إلى فكرة أن الأشخاص الذين تعرّضوا لحدث صادم يختبرون أفكارا ًومعتقدات غير مجدية مرتبطة بهذا الحدث وبعواقبه. هذه الأفكار والمعتقدات تؤدي إلى تجّنب غير مجٍد للمن بهات التذكيرية للحدث وتولد إحساسا ًبتهديد قائم. يتضمن العلاج عادة التعرّض لهذه المنبّهات التذكيرية ومواجهة الأفكار أو المعتقدات غير المجدية المتعلقة بالصدمة. العلاج النفسي بين الأشخاص lanosrepretnI (TPI) ypareht إنه علاج نفسي يركز على الصلة بين أعراض الاكتئاب والمشاكل ما بين الأشخاص، لاسيّما تلك التي تشمل خسارة، نزاعا،ً عزلة وتغيرات حياتية رئيسية. وصف أكثر من دواء في آن واحد لمعالجة الحالة المرضيّة نفسها.yparehtyloPالعلاج متعدد الأدوية إنه تنفس متسارع بشكل غير طبيعي، يؤدي إلى نقص الكربمية )كمية قليلة من noitalitnevrepyHفرط التهوية ثاني اكسيد الكربون في الدم(، ما قد يتسبّب بأعراض مميزة من إحساس بوخز الإبر والدبابيس في أصابع اليدين وحول الفم، ألم في الصدر ودوار. إنه أوراق نبتة كاتا ايديوليس )silude ahtaC( التي تحتوي على مادة منشطة. يعتبر tahKالقات على السواء مادة مدمنة ترويحية ومادة يمكن إساءة استخدامها تسبّب للشخص اعتمادا.ً إنه تدٍن غير طبيعي في نشاط الغدة الدرقية. عند البالغين، قد يتسبّب بمجموعة من msidioryhtopyHقصور الغدة الدرقية الأعراض مثل التعب والخمول وزيادة الوزن وانخفاض المزاج التي يمكن الخلط بينها وبين الاكتئاب. إذا كان قصور الغدة الدرقية موجودا ًمنذ الولادة ولم يتم علاجه، يمكن أن يؤدي إلى إعاقة ذهنية واخفاق في النمو. يشير إلى أجزاء نبتة القنب التي تستخرج منها الماريجوانا والحشيش وزيت الحشيش، sibannaCالقنب وكلها يمكن تدخينها أو تناولها لإثارة الشعور بالنشوة والاسترخاء والتصورات المتغيرة كما يمكنها تخفيف الألم. التأثيرات الضارة للقنب هي فقدان الحافز والهياج والبارانويا. worram enoBكبت نخاع العظم noisserped إنه انعدام لوظيفة نخاع العظم يمكن أن يؤدي إلى اختلال في إنتاج خلايا الدم. المتلازمة الخبيثة للدواء المضاد للذهان citpelorueN tnangilam emordnys إنها اضطراب نادر يشكل خطرا ًعلى حياة الانسان، سببه الأدوية المضادة للذهان. وهو يتّسم بأعراض مثل الحّمى، والهذيان، وتصلب العضلات وارتفاع ضغط الدم. إنها حالة وراثية سببها وجود كروموسوم إضافي 1۲ وهي ترتبط بدرجات متفاوتة من emordnys nwoDمتلازمة داون 26الإعاقة الذهنية، بتأخر في النمو الجسدي وبملامح مميزة في الوجه. متلازمة ستيفنز جونسون nosnhoJ-snevetS emordnys إنها مرض جلدي يشكل خطرا ًعلى حياة الشخص، وهو يتّسم بتقشر مؤلم للجلد وبتقّرح وفقاعات وجلبات في الأنسجة المخاطية مثل الفم والشفاه والحنجرة واللسان والعينين والأعضاء التناسلية. يكون أحيانا ًمصحوبا ًبحّمى. وهو ناجم في أغلب الأحيان عن تفاعل شديد مع الأدوية لاس يما مضادات الصرع. مضادات الالتهاب اللاستيرويدية ladiorets-noN -itna yrotammaflni (sDIASN) sgurd إنها مجموعة من الأدوية المستخدمة للقضاء على الالتهاب وهي تستخدم في كثير من الأحيان لتخفيف الألم )على سبيل المثال، الايبوبروفين هو DIASN(. إنه مصطلح يشير إلى العمليات الذهنية المرتبطة بالتفكير كالتحليل، والتذكر، والحكم، وحل evitingoCمعرفي المشاكل والتخطيط. نقص جلوكوز الدم إنه تدٍن غير طبيعي لتركيز الجلوكوز )لسكر( في الدم.aimeacylgopyH إنه تدٍن غير طبيعي لتركيز الصوديوم )الملح( في الدم.aimeartanopyHنقص الصوديوم enidoI نقص اليود ycneicfied إنه افتقار الجسم لليود الضروري لإنتاج الهرمونات الدرقية الطبيعي، وهو يؤثر في النمو. إنها حالة من الخلل الوظيفي الدماغي الناجم عن شحنات كهربائية غير طبيعية في الدماغ.eruzieSالنوبة "النوبة الكاذبة أو الوهمية" تبدو كنوبة صرع لكنها ليست كذلك في الواقع. يمكنها أن تحاكي نوبات الصرع بشدة من حيث eruziesoduesP التغيرات في الوعي والحركة، على الرغم من أن عض اللسان والكدمات القوية الناجمة عن السقوط وسلس البول أمور نادر حدوثها. مثل هذه النوبات لا تظهر النشاط الكهربائي لنوبات الصرع. ولا تعود الأعراض لحالة عصبية أو للتأثيرات المباشرة لمادة أو دواء. في المراجعة الحادية عشرة للتصنيف الدولي للأمراض 11-DCI، هذه النوبات مذكورة تحت عنوان الاضطراب الحركي الانشقاقي. إنه حالة نفسية متقلبة مؤقتة تتّسم بتشوش الانتباه )أي قدرة منخفضة على توجيه وتركيز muirileDالهذيان وتثبيت ونقل الانتباه( وتشوش الوعي )أي تقلص الاهتداء بالمحيط( تنشأ في فترة زمنية قصيرة وتميل إلى التقلب خلال اليوم. تصحبها اضطرابات )أخرى( في الإدراك أو الذاكرة أو التفكير أو المشاعر أو الوظائف النفس حركية. وقد تكون أسبابها عضوية حادة مثل العدوى أو الأدوية أو الاضطرابات الاستقلابية أو التسّمم بمواد الإدمان أو الانقطاع عن مواد الإدمان. إنها إدراك خاطئ للواقع حيث يرى الشخص أو يسمع أو يحس أو يشم أو يتذوق أشياء غير noitanicullaHالهلوسة حقيقية. إنه اعتقاد ارسخ مخالف للأدلة المتوافرة لا يمكن تغييره بالجدال العقلاني ولا يقبله الأفراد noisuleDالوهم الآخرون في ثقافة الشخص أو ثقافته الثانوية )أي أنه ليس جانبا ًمن المعتقد الديني(. إنها تقنية قلب الشخص من جانب لآخر دون ثني العنق أو الظهر تفاديا ًلإلحاق الأذى بالنخاع llor-goL الشوكي. مضادات الاكتئاب المانعة لإعادة امتصاص السيروتونين الانتقائية: إنها فئة من مضادات IRSS الاكتئاب التي تمنع انتقائيا ًإعادة امتصاص السيروتونين. السيروتونين هي مرسال كيميائي )ناقل عصبي( في الدماغ يؤثر في مزاج الشخص. الفلوكستين هو IRSS. مضادات الاكتئاب ثلاثية الحلقات: إنها فئة من مضادات الاكتئاب المانعة لإعادة امتصاص ACT الناقلين العصبيين، السيروتونين والنورادرينالين. على سبيل المثال، نذكر الاميتريبتيلين 36والكلوميبرامين. الملحق 3: قائمة الأعراض اضطراب الكرب ما بعد الصدمة )DSTP(الكرب الحاد )UCA(الارتجاع الكرب الحاد )UCA(الأرق الحزن )IRG( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( اضطراب الكرب ما بعد الصدمة )DSTP( التعاطي الضار للكحول ومواد الإدمان )BUS( الأعراض البدنية غير المفسرة الكرب الحاد )UCA( الحزن )IRG( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( اضطراب الكرب ما بعد الصدمة )DSTP( الكرب الحاد )UCA(انخفاض مستوى التركيز الحزن )IRG( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( اضطراب الكرب ما بعد الصدمة )DSTP( التعاطي الضار للكحول ومواد الإدمان )BUS( الكرب الحاد )UCA(الانسحاب الاجتماعي الحزن )IRG( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( الذهان ) YSP ( الكرب الحاد )UCA(الانفعال الحزن )IRG ( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( اضطراب الكرب ما بعد الصدمة )DSTP( التعاطي الضار للكحول ومواد الإدمان )BUS( الذهان )YSP(الأوهام الانتحار )IUS(إيذاء الذات الكرب الحاد )UCA(التبّول اللاإداي الإعاقة الذهنية )DI( الذهان )YSP(التشّوش الصرع/النوبات )IPE( التعاطي الضار للكحول ومواد الإدمان )BUS( الكرب الحاد )UCA(الذكريات الاقتحامية الحزن )IRG( اضطراب الكرب ما بعد الصدمة )DSTP( الصرع/النوبات )IPE(السلس 46الإعاقة الذهنية )DI( صعوبة في القيام بالأنشطة العادية الكرب الحاد )UCA( الحزن )IRG( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( اضطراب الكرب ما بعد الصدمة )DSTP( الذهان )YSP( الإعاقة الذهنية )DI( التعاطي الضار للكحول ومواد الإدمان )BUS( الكرب الحاد )UCA(فرط التهوية الحزن )IRG(فقدان الطاقة الاضطراب الاكتئابي المعتدل إلى الحاد )PED( الكرب الحاد )UCA(قلة الاهتمام/الاستمتاع الحزن )IRG( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( الذهان )YSP(قلة النظافة الشخصية الإعاقة الذهنية )DI( التعاطي الضار للكحول ومواد الإدمان )BUS( الكرب الحاد )UCA(القلق الاضطراب الاكتئابي المعتدل إلى الحاد )PED( اضطراب الكرب ما بعد الصدمة )DSTP( الذهان )YSP( التعاطي الضار للكحول ومواد الإدمان )BUS( الحزن )IRG(المزاج الحزين الاضطراب الاكتئابي المعتدل إلى الحاد )PED( الإعاقة الذهنية )DI(مشاكل التعلم الكرب الحاد )UCA(مشاكل الشهية الحزن )IRG( الاضطراب الاكتئابي المعتدل إلى الحاد )PED( الصرع/النوبات )IPE(النوبات/التشنجات التعاطي الضار للكحول ومواد الإدمان ( BUS( الذهان )YSP(الهلوسات التعاطي الضار للكحول ومواد الإدمان )BUS( الحزن )IRG(اليأس الاضطراب الاكتئابي المعتدل إلى الحاد )PED( الانتحار )IUS( 56 خلال حالات الطوارئ الإنسانية، يجب أن يتولى موظف واحد على الأقل خاضع للإشراف من طاقم الرعاية الصحية داخل كل مرفق صحة عامة عملية تقييم وتدبير الاضطرابات النفسية والعصبية واستخدام مواد الإدمان. يشكل دليل التدخلات الإنسانية لبرنامج رأب الفجوة في الصحة النفسية )GIH-PAGhm( أداة عملية بسيطة تهدف إلى تحقيق هذا الهدف. برنامج رأب الفجوة في الصّحة النفسية

Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies mhGAP Humanitarian Intervention Guide জরুরি মানরিক পরিরিরিতি মানরিক, স্নায়রুিক ও মাদকদ্রিয িযািহািজরনি রিরকৎিা িযািিাপনা এম এইচ গ্যাপ মানবিক ইন্টারভেনশন গ্াইড ( এমএইচ গ্যাপ – এইচআইবি) জরুরি মানরিক পরিরিরিতি মানরিক, স্নায়রুিক ও মাদকদ্রিয িযািহািজরনি রিরকৎিা িযািিাপনা এম এইচ গ্যাপ মানবিক ইন্টারভেনশন গ্াইড (এমএইচ গ্যাপ – এইচআইজি) Published by the World Health Organization and the United Nations High Commissioner for Refugees in 2015 under the title ‘mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Emergencies.’ © World Health Organization 2015 The World Health Organization has granted translation and publication rights for an edition in Bengali to Action Against Hunger, which is solely responsible for the quality and faithfulness of the Bengali translation. In the event of any inconsistency between the English and the Bengali edition, the original English edition shall be the binding and authentic edition. এম এইচ গ্যাপ মানবিক ইন্টারভেনশন গ্াইড (এমএইচ গ্যাপ – এইচআইবি): িরুবর মানবিক পবরবিবিভি মানবিক, স্নায়ুবিক ও মাদকদ্রিয িযািহারিবনি বচবকৎিা িযািিাপনা © Action Against Hunger 2020 বিশ্ব স্বািয িংিা এই ডকুভমন্টবট িাংলা োষায় অনুিাদ ও প্রকাশনার িন্য একশন এভগ্ইন্সট হাঙ্গার-কক অবিকার অপপন কভরভে , িাংলায় যার মান ও যথাথপিার িন্য ককিল এই প্রবিষ্ঠানই দায়ী। ইংভরবি ও িাংলা িংস্করভের মভিয ককান িরভনর অিঙ্গবি থাকভল মূল ইংভরবি িংস্করেই হভি িািযিামূলক ও প্রামান্য িংস্করে। 3 Abyev`K: A¨vKkb G‡Mb&÷ nv½vi g~j ch©v‡jvPbvKvix: (A¨vKkb G‡Mb&÷ nv½v‡ii c‡ÿ) wgZv ivwb ivq †PŠayix, bvCgv RvbœvZ, gy³v Rvnvb evby| Ab¨vb¨ ch©v‡jvPbvKvix: †gvnv¤§` wRjøyi ingvb Lvb (wW‡i±‡iU †Rbv‡ij Ae †nj_ mvwf©‡mm/¯v^¯’¨ Awa`ßi), Gg. Gg. Rvjvj DwÏb (b¨vkbvj Bbw÷wUDU Ae wbD‡ivmv‡q‡Ým I nvmcvZvj), Kvgvj DwÏb Avn‡g` †PŠayix (XvKv wek¦we`¨vjq), kvn&wiqvi dviæK (e½eÜz †kL gywRe †gwWK¨vj wek¦we`¨vjq), mvBdzb& bvnvi (RvZxq gvbwmK ¯^v¯’¨ Bbw÷wUDU), †Rmvb Aviv (ivRkvnx wek¦we`¨vjq), RvbœvZzj †di‡`Šm (Gg.wdj M‡elK, XvKv wek¦we`¨vjq), †gv: Avãyi iv¾vK (n¨vwÛK¨vc B›Uvib¨vkbvj), Zvnwgbv nK (Iqvb÷c µvBwmm †m›Uvi, XvKv †gwW‡Kj K‡jR), †gv: Igi dviæK (Gg.wdj M‡elK, XvKv wek¦we`¨vjq), ïå cÖKvk †` (AvšÍR©vwZK Awfevmb ms ’¯v-AvBIGg) m~wPcÎ K…ZÁZv ¯^xKvi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . f~wgKv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 wPwKrmv e¨e¯’vcK‡`i Rb¨ wb‡`©kbv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 gvbweK cwiw¯’wZ‡Z gvbwmK, ¯œvqyweK I gv`K`ªe¨ e¨enviRwbZ Ae¯’vq mvaviY g~jbxwZ (GPC) 10 1| †hvMv‡hv‡Mi bxwZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2| A¨v‡mm‡g‡›Ui bxwZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3| e¨e¯’vcbvi bxwZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 4| gvbwmK Pvc Kgv‡bv I mvgwRK mnvqZv e„w×i bxwZ . . . . . . . . . . . . . . . . . . . . . . . . . 13 5| gvbevwaKvi i¶vi bxwZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 6| mvgwMÖKfv‡e fv‡jv _vKvq g‡bv‡hvM †`Iqvi bxwZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 gwWDjmg~n 1| Zxeª gvbwmK Pvc (ACU) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 2| Zxeª †kvK (GRI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 3| gvSvwi-¸iæZi welYèZv (DEP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 4| †cv÷-UªgvwUK †÷ªm wWmAW©vi (PTSD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 5| mvB‡Kvwmm (PSY) . . . . . . . . . . . . . . . . . .. . . . .. . . . . . . . .. . . . . . . . . . .40 6| g„Mx‡ivM/wLuPzbx (EPI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 7| eyw× cÖwZeÜx (ID) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 8| A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi (SUB) . . . . . . . . . . . . . . . . . . . . . . . . . .56 9| AvZ¥nZ¨v (SUI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 10| Ab¨vb¨ ¸iæZ¡c~Y© gvbwmK ¯^v¯’¨ cxov (OTH) . . . . . . . . . . . . . . . . . . . . . . . . . . 65 cwiwkó Annex 1: UNHCR (2014) ¯^v¯’¨ Z_¨ c×wZ (HIS) NUbvi weeiY . . . . . . . . . . . . . . 68 Annex 2: UxKv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Annex 3: j¶Y m~wP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 7 f~wgKv Riæwi gvbweK cwiw¯’wZ‡Z gvbwmK, ¯øvqyweK I gv`K`ªe¨ e¨enviRwbZ †iv‡Mi Awe‡klvwqZ wPwKrmv e¨e¯’vq cÖ‡qv‡Mi Rb¨ GB wb‡ ©`wkKv WHO mhGAP B›Uvi‡fbkb MvB‡Wi (mhGAP-IG) Awf‡hvRb| †mB Abyhvqx, G‡K mhGAP gvbweK B›Uvi‡fbkb MvBW (mhGAP-HIG) ejv n‡e| mhGAP wK? Mental health Gap Action Programme (mhGAP) nj WHO Gi GKwU Kg©m~wP, hv gvbwmK, ¯øvqyweK I gv`K`ªe¨ e¨enviRwbZ (MNS) †iv‡M AvµvšÍ gvby‡li †mevi AcÖvwß wb‡q KvR K‡i| GB Kg©m~wPi Ask wn‡m‡e, mhGAP Intervention Guide (mhGAP-IG) 2010 mv‡j cÖKvk Kiv nq| mhGAP-IG gvbwmK, ¯œvqyweK I gv`K`ªe¨ e¨envi RwbZ †iv‡Mi †ÿ‡Î mvaviY ¯^v¯’¨‡mev `vbKvix‡`i Rb¨ wPwKrmv wb‡ ©`wkKv, whwb Awe‡klvwqZ ¯^v¯’¨‡mevi †mwUs‡m KvR K‡ib, we‡kl K‡i ¯^í I ga¨ Av‡qi †`k¸‡jv‡Z| mvaviY wPwKrmK, †mweKv, avÎx I wPwKrmv Kg©KZ©v, Ges we‡klÁ wPwKrmKMY, hviv mvBwKqvwUª ev wbD‡ivjwRi bb, Zviv Gi AšÍfz©³| wPwKrmv wb‡ ©`wkKvi evB‡i mhGAP Kg©m~wP †cÖvMÖvg ev¯Íevq‡b mnvqZvi Rb¨ A‡bK DcKiY mieivn K‡i, hv cwiw¯’wZ we‡kølY, GjvKvi cwi‡cÖwÿ‡Z wPwKrmvi †mŠRb¨wewa Awf‡hvRb, Kg© cwiKíbv MÖnY, cÖwk¶Y, ZË¡veavb I ch©‡e¶‡Y Kv‡R Av‡m| Riæwi gvbweK cwiw ’¯wZ‡Z Awf‡hvR‡bi cÖ‡qvRb †Kb? Riæwi gvbweK cwiw¯’wZi g‡a¨ eo cwim‡i Zxeª I `xN©¯’vqx Riæwi Ae¯’v AšÍfz©³, hv mk¯¿ msNvZ Ges cÖvK…wZK I wkí Dfq wech©q †_‡K D™¢yZ| Riæwi gvbweK cwiw¯’wZ‡Z mvaviYZt gvby‡li MY¯’vbvšÍ‡ii welqwU N‡U _v‡K| G Ae¯’vq IB gvbyl¸‡jvi †gŠwjK cwi‡mevi cÖ‡qvRb ¯’vbxq m¶gZvi evB‡i P‡j hvq, †h‡nZz Riæwi Ae¯’vi Kvi‡Y GjvKvi k„•Ljv ¶wZMÖ¯Í n‡Z cv‡i| ¯’vbxq, RvZxq I AvšÍR©vwZK gvbweK mvnv‡h¨i cwigvY I cÖvc¨Zvi wfwˇZ m¤ú‡`i cwigvY cwiewZ©Z nq| gvbweK msKU¸‡jv A‡bK P¨v‡j‡Äi Rb¥ †`q, GKB mv‡_ ¯^v¯’¨ †mev `vbKvix‡`i Rb¨ Abb¨ my‡hvMI ˆZwi K‡i| my‡hvM¸‡jvi g‡a¨ i‡q‡Q gvbwmK ¯^v¯’¨ †mev DbœZ Kivi ivR‰bwZK mw`”Qv I m¤c` e„w×| 2 P¨v‡jĸ‡jvi g‡a¨ i‡q‡Q: » Ach©vß m¤ú‡`i AMÖvwaKvi Ges RiæwiwfwˇZ eiv‡Ïi cÖ‡qvRbxqZv evov‡bv » ¯^v¯’¨‡mev cÖ`vbKvix‡`i cÖwk¶‡Yi Rb¨ mxwgZ mgq » we‡klÁ†`i mxwgZ my‡hvM (cÖwk¶Y, ZË¡veavb, civgk©, †idvivj ev civgk©) » ¯^vfvweK mieivn †PBb wewNœZ nevi Kvi‡Y Jl†ai mxwgZ e¨envi| mhGAP gvbweK B›Uvi‡fbkb MvBWwU wbw`©ó P¨v‡jÄ †gvKv‡ejvi Rb¨ ˆZwi Kiv n‡q‡Q| GB MvB‡Wi welqe ‘¯t mhGAP gvbweK B›Uvi‡fbkb MvB‡W _vK‡Q GgGbGm Ae¯’vq Riæwi gvbweK cwiw¯’wZ‡Z mvaviY ¯^v¯’¨‡mev `vbKvix‡`i Rb¨ cÖ_g-mvwii e¨e¯’vcbv cÖ¯ Ívebv, †hLv‡b we‡klÁ I we‡klvwqZ wPwKrmv †mev mxwgZ| GB wb‡ ©`wkKv c~Y© mhGAP-IG †_‡K cÖ‡qvRbxq Z_¨ †ei K‡i †bq Ges gvbweK wech©‡qi wbw`©ó AwZwi³ Dcv`vb AšÍfy©³ K‡i| GB wb‡ ©`wkKvq Av‡Q: » wK¬wbK cwiPvjK‡`i Rb¨ civgk© » Riæwi gvbweK cwiw¯’wZ‡Z †mevi mvaviY g~jbxwZ, †hgb: ◆ Riæwi Ae¯’vq gvbwmK ¯^v¯’¨ I g‡bvmvgvwRK mnvqZvi AvBGGmwm bxwZgvjv (AvBGGmwm, 2007), DØv ‘¯ Acv‡ik†b gvbwmK ¯^v¯’¨ I g‡bvmvgvwRK mnvqZv †cÖvMÖvwgs‡qi Acv‡ikbvj MvB‡WÝ (BDGbGBPwmAvi, 2013) Ges Ab¨vb¨ Riæwi Ae¯’v m¤cwK©Z miÄvg Abyhvqx eûcvwÿK mnvqZv; ◆ Pvc Kgv‡bvi wb‡ ©`kvejx » g~j¨vqb I e¨e¯’vcbvi msw¶ß gwWDj: ◆ Zxeª Pvc (ACU) ◆ †kvK (GRI) ◆ gvSvwi-¸iæZi welYèZv (DEP) ◆ †cv÷v-UªgvwUK †÷ªm wWmAW©vi ev AvNvZ cieZ©x gvbwmK Pvc RwbZ gvbwmK †ivM (PTSD) ◆ mvB‡Kvwmm (PSY) ◆ g„Mx‡ivM/wLuPzwb (EPI) ◆ eyw× cÖwZewÜZv (ID) ◆ A¨vj†Kvnj I gv`‡Ki ¶wZKi e¨envi (SUB) ◆ AvZ¥nZ¨v (SUI) ◆ Ab¨vb¨ ¸iæZ¡c~Y© gvbwmK ¯^v¯’¨ cxov/Awf‡hvM (OTH). Ab¨vb¨ cwieZ©b¸‡jv wb¤œwjwLZ welq¸‡jv AšÍf©z³ K‡i: » eqtmwÜKv‡ji AvPiYMZ mgm¨v¸‡jvi Dci wb‡ ©`wkKv wnmv‡e AvPvi-AvPi‡Yi wb‡ ©`wkKvwU cybivq wjwce× Kiv n‡qwQj, hv Ab¨vb¨ D†jøL‡hvM¨ gvbwmK ¯^v¯’¨ msµvšÍ Awf‡hvM¸‡jvi (OTH) gwWD‡j cvIqv †M‡Q| » A¨v‡mm‡g›U A¨vÛ g¨v‡bR‡g›U Ae `¨v KwÛkbm †¯úwmwdK¨vwj wi‡j‡UW Uz †÷ªm: GgGBPM¨vc B›Uvi‡fbkb MvBW gwWDj (WHO, 2013) 3wU gwWD‡j wef³: Zxeª gvbwmK Pvc (GwmBD), Zxeª †kvK (wRAviAvB) Ges †cv÷-UªgvwUK †÷ªm wWmW©vi (PTSD)| » GKwU kã‡Kvl †hvM Kiv n‡q‡Q| ZviKv wPý * Øviv wPwýZ kZ©¸‡jv A¨v‡b· 2 G eY©bv Kiv n‡q‡Q| GB MvBWwU mhGAP-IG Gi Zzjbvq †QvU| G‡Z wb‡ ©`wkKv _v‡K bv: » A¨vj‡Kvnj Ges gv`Kvmw³ Ges wbf©iZv * (hw`I, A¨vj‡Kvnj cÖZ¨vnvi Ges ¶wZKviK A¨vj‡Kvnj I gv`K`ªe¨ e¨envi GB MvB‡W ewY©Z); » g‡bv‡hv‡Mi NvUwZ AwZ PÂjZv †Mvj‡hvM (Z‡e, wK‡kvi AvPiYMZ mgm¨v GB MvB‡Wi Ab¨vb¨ ¸iæZ¡c~Y© gvbwmK ¯^v¯’¨ msµvšÍ Awf‡hv‡Mi gwWD‡j Av†Q); » AwURg †¯cKUªvg wWRAWvim ©; » wW‡gbwkqv (hvB‡nvK, †KvbI GgGbG‡mi Ae¯’vi gvby‡li mnvqZvi Rb¨ mvaviY bxwZgvjv GB MvB‡Wi AšÍfy©³); » wb‡Ri ¶wZ ev AvNvZ Gi SzuwK GB gyû‡Z © Ki‡e Ggb bq; » AwaKvsk GgGbGm kZ©¸‡jvi Rb¨ wØZxq jvBb wPwKrmv cieZ©x wel‡qi Dci wb‡ ©`kbv m¤c~Y© GgGBPM¨vc-AvBwR-‡Z cvIqv hvq| 1 Email mhgap-info@who.int to obtain a copy of these tools.2 See World Health Organization (WHO). 2 Building back better: sustainable mental health care after emergencies. WHO: Geneva, 2013. wPwKrmv e¨e¯’vcK‡`i Rb¨ civgk© mvaviY ¯^v¯’¨‡mevq gvbwmK, ¯œøvqyweK I gv`K`ªe¨ e¨envi RwbZ (GgGbGm) mgm¨vi mgš^q GKRb †bZvi (†hgb †Rjv ch©v‡qi miKvwi ¯^v¯’¨ Kg©KZ©v, ms¯’v wPwKrmv cwiPvjK, BZ¨vw`) Aax‡b n‡Z n‡e, hv‡Z whwb ¯^v¯’¨ myweavi cÖvmw½K Ae¯’vi we‡køl‡Yi wfwˇZ cwiKíbv I mgš^q mvab Ki‡eb (WHO& UNHCR [2012] G‡mm‡g›U UzjwKU †`Lyb)| cÖwZwU †mevq wbw`©ó `vwqZ¡ mnKv‡i GKRb wK¬wbK g¨v‡bRvi (¯^v‡¯’¨ myweavi cÖavb) i‡q‡Q| wK¬wbK e¨e¯’vcK‡`i wb¤œwjwLZ welq we‡ePbv Kiv cÖ‡qvRb| cwi‡ek » GgGbGm cwiw¯’wZ‡Z Av‡jvPbvi Rb¨ GKwU GKvšÍ ¯’vb, we‡kl K‡i c„_K K‡ÿi e¨e¯’v Kiæb| hw` c„_K Kÿ mnRjf¨ bv nq, m‡e ©v”P †MvcbxqZv eRvq ivLvi Rb¨ c ©`v ev Ab¨vb¨ Dcv‡q Kÿ fvM Kivi †Póv Kiæb| » we‡ePbv Kiæb KÿwU wPwýZ bv nq, †hb GgGbGm cwi‡levi †ÿ‡Î mvgvwRK w÷Mgvi f‡qi evB‡i _v‡K| cwi‡lev g‡Wj » AšÍZ GKRb cÖwkw¶Z Kg©x m`m¨‡K "GgGbGm wWDwU" G me mg‡q kvixwiKfv‡e Dcw¯’Z _vKv we‡ePbv Kiæb, †hgb- GgGbGm cwiw¯’wZ‡Z †hb GKRb e¨w³ gvbyl‡`i g~j¨vqb I cwiPvjbv Ki‡Z cv‡ib| » weKífv‡e, wK¬wbK Kg e¨¯Í n‡j w`‡bi GKwU mvaviY ¯^v¯’¨ myweavi g‡a¨ GKwU mvßvwnK ev wØ-mvßvwnK "GgGbGm wK¬wbK" ivLv we‡ePbv Kiæb| hw` A-GgGbGm wK¬wb‡Ki mgq gvbyl †`‡Lb, Z‡e wK¬wbKwU hLb AbywôZ n‡”Q ZLb Zv‡`i‡K ¯^”Q‡›` wd‡i Avm‡Z ejv n‡e| †hgb, GgGbGm wK¬wbK ¯’vcb Kiv e¨¯Í ¯^v‡¯’¨i myweav¸‡jv‡Z mnvqK n‡Z cv‡i, we‡kl K‡i cÖv_wgK g~j¨vqb cwiPvjbvi Rb¨, hv d‡jv-Avc wfwR‡Ui †P‡q †ewk mgq †bq| ÷vwds Ges cÖwk¶Y » GgGbGm cwiw¯’wZ‡Z gvb y‡li mv‡_ mnvqK cwi‡ek ˆZwi Ki‡Z mKj Kg©x†K msw¶ß weeiY †`qv| » GgGbGm h‡Zœ cÖwk¶‡Yi Rb¨ Kg©x‡`i wPwýZKiY| » wbwðZ Kiæb †h m¤c` ïaygvÎ cÖwk¶‡Yi Rb¨B bq, eis ZË¡veav‡bi Rb¨I| Kg©x‡`i wK¬wbK¨vj ZË¡veavb fvj GgGbGm hZœ Gi GKwU Acwinvh© Ask| » hw` †KejgvÎ K‡qKRb Kg©x GB wb‡ ©`wkKvwUi welqe¯‘ m¤c‡K© cÖwk¶Y jvf Ki‡Z cv‡ib, Z‡e wbwðZ Kiæb †h evwK wK¬wbK¨vj Kg©xiv AšÍZc‡¶ cÖv_wgK gb¯ÍvwË¡K mnvqZv (wcGdG)* w`‡Z cv‡i| AvbygvwbK A‡a©K w`b wcGGdGi cwiwPwZ cÖ`vb Kiv †h‡Z cv‡i| wdì IqvK©vi‡`i Rb¨ cÖv_wgK gb¯ÍvwË¡K mnvqZv MvBW Ges †dwmwj‡UUi Iwi‡q‡›Ukb DcKiY¸‡jv AbjvB‡b mn‡R cvIqv hv‡e| » D‡ËwRZ e¨w³‡`i †gvKv‡ejv Kivi Rb¨ wi‡mckwb÷ (ev Abyiƒc f‚wgKvhy³ e¨w³) †K AwfwnZ Kiæb, hviv Awej‡¤^ g‡bv‡hvM ev Pvwn`v †gUv‡Z cv‡i| » Rbmvavi‡Yi Kg©x I †¯^”Qv‡mex‡`i cÖwk¶Y w`b, hw` mnRjf¨ nq wKfv‡e (K) GgGbGm hZœ m¤c‡K© m‡PZbZv m„wó Kiv (bx‡Pi †`Lyb), (L) wK¬wb‡Ki mvnv‡h¨i Rb¨ Avmv GgGbG‡mi gvbyl‡K mnvqZv Kiæb Ges (M) d‡jv-Avc h‡Zœ mnvqZv| » †nj_ †Kqvi wU‡gi (GKRb bvm©, GKRb g‡bvweÁvbxi Kg©x, GKRb KwgDwbwU mgvR Kg©x) KvD‡K `vwqZ¡ w`b, whwb cÖwkÿY †b‡eb Ges ZË¡veavq‡Ki Aax‡b †_‡K g‡bvmvgvwRK mnvqZv †`‡eb (†hgb- mswÿß g‡bv‰eÁvwbK wPwKrmv, †mjd-†njc `j cwiPvjbv, †÷ªm g¨v‡bR‡g›U †kLv‡bv)| » ¯’vbxq myi¶v e¨e¯’vi Dci me ÷vd‡K AewnZ Kiæb: ◆ cÖ‡qvRbxqZv Ges m¤§wZi mxgve×Zv, m‡›`nfvRb wkï wbh©vZb, †hŠb I wj½ wfwËK mwnsmZv Ges Ab¨vb¨ gvbevwaKvi j•N‡bi weiæ‡× Rvbv‡bv; ◆ cwievi mbv³KiY, Lyu‡R †ei Kiv I GKwÎZ Kiv| we‡kl K‡i wew”Qbœ wkï‡`i myiw¶Z Ki‡Z n‡e Ges cÖ‡qvRb n‡j h_vh_ A¯’vqx †Kqvi e¨e¯’v¸‡jv‡Z cvVv‡Z n‡e| » AvšÍR©vwZK gvbwmK ¯^v¯’¨ †ckvRxex‡`i mycviwfkb cÖ`v‡bi Rb¨ wK¬wb‡Ki mv‡_ mshy³ Kiv n‡j, Zv‡`i ¯’vbxq ms¯‹…wZ I †cÖÿvcU m¤c‡K© aviYv w`‡Z n‡e| » me ÷vd†K AwfwnZ Kiæb wKfv‡e mnRjf¨ †mevq Zv‡`i cvVv‡bv hvq| †idv‡ij » wbwðZ Kiæb †h, wK¬wb‡K GgGbGm Ae¯’vi †mevq cvVv‡bvi Rb¨ GKwU mv¤úªwZK †hvMv‡hv‡Mi ZvwjKv i‡q‡Q| » wbwðZ Kiæb †h, wK¬wb‡K †hb IB A‡ji Ab¨vb¨ mnRjf¨ Drm¸‡jvi GKwU mv¤úªwZK cwiwPwZ ZvwjKv _v‡K (D`vniY¯^iƒc †gŠwjK cÖ‡qvRb †hgb Avkªq I Lv`¨ mnvqZv, mvgvwRK I KwgDwbwU m¤c` Ges cwi‡lev¸‡jv, myi¶v Ges AvBwb mnvqZv)| 9 mnRjf¨ †mev m¤c‡K© m‡PZbZv e„w×: » mnRjf¨ GgGbGm †mev m¤c‡K© KwgDwbwUi Rb¨ evZ©v cÖ¯‘Z Kiæb (†hgb, D‡Ïk¨ I GgGbGm †mevi ¸iæZ¡, wK¬wb†Ki mnRjf¨ †mev, wK¬wb†Ki Ae¯’vb I mgq)| » KwgDwbwU †bZv‡`i mv‡_ evZ©v¸‡jv wb‡q Av‡jvPbv Kiæb| » wewfbœ Z_¨ weZiY P¨v‡bj e¨envi Kiæb, †hgb- †iwWI, ¯^v¯’¨ wK¬wb‡K †cv÷vi, KwgDwbwU Kg©x ev Ab¨vb¨ m¤cÖ`v‡qi mvaviY gvbyl hv‡Z Rvb‡Z cv‡i| » †hLv‡b Dchy³, ¯’vbxq Avw`evmx I HwZn¨evnx †mev `vbKvix‡`i mv‡_ evZ©v¸‡jv wb‡q Av‡jvPbv Ki‡Z cv‡ib, GgGbGm Ae¯’vq hviv †mev cÖ`vb Ki‡Z cv‡ib Ges hviv wKQz wKQz †¶‡Î mn‡hvwMZv Ki‡Z I †idvi Ki‡Z cv‡ib| (wb‡`©wkKv Rb¨, AvBGGmwm wb‡ ©`wkKv¸‡jvi A¨vKkb wkU 6.4 †`Lyb) (IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings [IASC,2007]). » cÖvwšÍK Rb‡Mvôxi Kv‡Q hvb, hviv wK¬wbK m¤c‡K© AeMZ bq ev cÖ‡ekvwaKvi bvI _vK‡Z cv‡i| Ilya » Acwinvh© Ily‡ai mve©¶wYK mieivn wbwðZ Ki‡Z mswkøó wm×všÍ MÖnYKvixi m‡½ KvR Kiæb| » mnRjf¨Zv wbwðZ Kiæb: ◆ AšÍZ GKwU Gw›UmvB‡KvwUK Jla (U¨ve‡jU I Bb‡RKkb dg©) ◆ Kgc‡¶ GKwU A¨vw›U-cviwKbm‡bi Jla (m¤¢ve¨ cvk¦© cÖwZwµqv †gvKv‡ejvi Rb¨) * (U¨ve‡jU dg©) ◆ AšÍZ GKwU anticonvulsant/antiepileptic Jla (U¨ve‡jU dg©) ◆ Kgc‡¶ GKwU Gw›UwW‡cÖ‡m›U †gwWwmb (U¨ve‡jU dg©) Ges ◆ AšÍZ GKwU D‡ØM wb‡ivax Jla (U¨ve‡jU I Bb‡RKkb dg©) » Avcwb B›Uvi-G‡RwÝ Bgvi‡RwÝ †nj_ wKU (IEHK) (WHO, 2011), †c‡Z cv‡ib, hv cÖavb gvbweK wech©‡qi wkKvi 10 nvRvi gvby‡li 3 gvm cÖv_wgK ¯^v¯’¨‡mevi cÖ‡qvRb †gUv‡Z cwiKwíZ Ilya I wPwKrmv mieiv‡ni GKwU eo e·| ◆ wb¤œwjwLZ mvB‡Kv‡UªvwcK Ilya¸‡jv IEHK-†Z AšÍfz©³- ▸Amitriptyline tablets: 25 mg tablet x 4000 ▸Biperiden tablets: 2 mg tablet x 400 ▸Diazepam tablets: 5 mg tablet x 240 ▸Diazepam injections: 5 mg/ml, 2 ml/ampoule x 200 ▸Haloperidol tablets: 5 mg tablet x 1300 ▸Haloperidol injections: 5 mg/ml; 1 ml/ampoule x 20 ▸Phenobarbital tablets: 50 mg x 1000. ◆ IEHK- †Z Ily‡ai cwigvY †cÖvMÖvg¸‡jvi Rb¨ h‡_ó bq hv µgvMZ g„Mx†ivM, mvB‡Kvwmm I welYœZv mbv³ Ges wbqš¿Y Ki‡e| AwZwi³ Ily‡ai Av‡`k †`qv cÖ‡qvRb| ◆ `xN©†gqv‡`, cÖ‡qvRbxq Ily†ai cÖK…Z e¨env†ii cwigvY Rvbv DwPZ| » gb¯ÍvwË¡K Ilya QvovI, ¯^-¶wZi/ wb‡R‡K AvNvZ Kivi GKwU mvaviY iƒc Zxeª KxUbvk‡Ki welwµqvq e¨e¯’vcbvi Rb¨ G‡UªvcvBb cvIqv DwPZ| IEHK-†Z A¨v‡UªvcvBb _v‡K (1mg/ml, 1 ml/ampoule x 50). » me Jla hv‡Z wbivc‡` msi¶Y Kiv nq Zv wbwðZ Kiæb| Z_¨ e¨e¯’vcbv » †MvcbxqZv wbwðZ Kiæb: ¯^v¯’¨ Z_¨ wbivc‡` msi¶Y Ki‡Z n‡e| » †nj_ Bbdi‡gkb wm‡÷‡g †`qvi Rb¨ cÖ‡qvRbxq Z_¨ mbv³ Kiæb| ◆ GgGbGm †iv‡Mi (A¨v‡b· 1 †`Lyb) WKz‡g‡›Uk‡bi Ici bxwZgvjvi Rb¨ BDGbGBPwmAvi †nj_ Bbdi‡gkb wm‡÷‡gi 7 K¨vUvMwii wbD‡ivmvBwKqvwUªK Dcv`vb e¨envi Kiæb| ◆ eo cwim‡i, Pig Riæwi cwiw¯’wZ‡Z Rb¯^v¯’¨ wb‡q bxwZ-wba©viKiv †nj_ Bbdi‡gkb wm‡÷‡g 7wU AvB‡Ug †hvM Ki‡Z cÖ¯‘Z bvI _vK‡Z cv‡ib| GB Ae¯’vq, AšÍZ c‡ÿ ÔgvbwmK, ¯œvqyweK I gv`K`ªe¨ e¨enviRwbZ Ae¯’vÕ kxl©K AvB‡Ug †nj_ Bbdi‡gkb wm‡÷‡g hy³ Ki‡Z n‡e| mg‡qi mv‡_ mv‡_ Av‡iv we¯Í…Z wm‡÷‡g GB AvB‡UgwU cÖwZ¯’vwcZ n‡e| » Z_¨ msMÖn I we‡kølY Kiæb Ges Gi djvdj m¤ú‡K© mswkøó Rb¯^v¯’¨ bxwZ wba©viK‡`i AewnZ Kiæb| gvbweK cwiw¯’wZ‡Z gvbwmK, œ¯vqyweK I gv`K`ªe¨ e¨enviRwbZ †mevi mvaviY g~jbxwZ 1. †hvMv‡hv‡Mi bxwZmg~nt `ªæZ cwiewZ©Z Ges AbvKvw•ÿZ gvbweK cwi‡e‡k, ¯^v¯’¨ †mev `vbKvixiv ¯^í mg‡q A‡bK †ewk gvbyl †`L‡Z wM‡q wecyj Pv†c c‡ob| ¯^v¯’¨ †K‡› ª` civgk©¸‡jv msw¶ß, bgbxq nIqv Ges me‡P‡q Riæwi welq¸‡jvi Ici `„wó wbe× Kiv cÖ‡qvRb| fvj †hvMv‡hvM `¶Zv ¯^v¯’¨ †mev `vbKvix‡`i GB j¶¨ AR©b Ki‡Z mvnvh¨ Ki‡e Ges gvbwmK, ¯œvqyweK I gv`K `ªe¨ e¨envi (MNS) RwbZ mgm¨vq cÖvßeq¯‹, wK‡kvi I wkï‡`i Kvh©Ki †mev w`‡Z mvnvh¨ Ki‡e| » Db¥y³ †hvMv‡hvM myweav †`qvi g‡Zv cwi‡ek ˆZwi Kiæb ◆ m¤¢e n‡j cÖvB‡fU ¯’v‡b e¨w³i mv‡_ †`Lv Kiæb| ◆ e¨w³i †PvL eivei emyb (D`vniY¯^iƒc, hw` e¨w³wU e‡m _v‡K, Zvn‡j AvcwbI emyb) ◆ e¨w³†K ¯^vMZ Rvbvb, Avcbvi cwiPq w`bmGes Avcbvi Ae¯’vb ejyb, mvs¯‹…wZKfv‡e Dchy³ f‚wgKv w`b| ◆ cÖ‡Z¨‡Ki Dcw¯’wZ‡K Awfev`b Rvbvb| ◆ e¨w³‡K wRÁvmv Kiæb †h wZwb / Zvi hZœ`vZv ev Ab¨vb¨ e¨w³‡`i ivL‡Z Pvb wKbv? ▸ e¨w³ †QvU wkï bv n‡j, hw` m¤¢e nq, GKv GKv K_v ej‡Z ejyb| hw` †KD Ab¨‡K ivL‡Z Pvb, Zvn‡j Zv m¤§vb Kiæb| ▸ hw` Avcwb GKgvÎ e¨w³‡K †`L‡Z cvb, Zvn‡j Zv‡`i cwi‡cÖw¶‡Z †LvuRvi Rb¨ hZœKvix‡`i cÖvmw½K g~j¨vqb cÖkœ wRÁvmv Kivi AbygwZ wbb, Ges ∙ e¨e ’¯vcbv cwiKíbv Av‡jvPbv I m¤§Z nIqvi mgq hZœkxj†`i m¤c„³ Kiæb| ◆ e¨w³‡K Rvbvb †h Z_¨¸‡jv Av‡jvPbv Kiv n‡q‡Q Zv †Mvcb ivLv n‡e Ges Zvi AbygwZ QvovB KvD‡K Rvbv‡bv n‡e bv, †Kej Avcwb hLb e¨w³ ev Ab¨R‡bi Kv‡Q SzuwK Abyfe K‡ib (g‡b ivL‡eb †h GB evZ©vwU RvZxq †MvcbxqZvi AvBwb mxgv Abyhvqx Awf‡hvwRZ n‡Z cv‡i) » hZUzKz m¤¢e GgGbGm Gi Ae¯’vi mv‡_ e¨w³†K m¤c„³ Kiæb| ◆ GgbwK hw` e¨w³wUi Kvh©KvwiZv e¨vnZ nq, Z‡e Av‡jvPbvi g‡a¨ Zv‡`i memgq m¤c„³ Kivi †Póv Kiæb| GwU GgGbG‡mi Ae¯’vi mv‡_ wkï‡`i, hyeK I e„ׇ`i Rb¨I mZ¨| Zv‡`i hZœkxj‡`i m‡½ ïaygvÎ K_v ej‡Z Zv‡`i D‡c¶v Ki‡eb bv| ◆ Avcwb wK Ki‡Qb Ges Avcwb wK Ki‡Z hv‡”Qb, Zv me©`v e¨w³‡K e¨vL¨v Kivi †Póv Kiæb ( †hgbt kvixwiK cix¶vi mgq)| » †kvbvi gva¨‡g ïiæ Kiæb ◆ GKRb‡K GgGbG‡mi e¨w³‡K evav ej‡Z w`b| y`tLRbK gvbyl memgq GKwU cwi®‹vi BwZnvm w`‡Z cv‡i bv| hLb GwU NU‡e, ˆah¨© aiæb Ges ¯cóKi‡Yi Rb¨ wRÁvmv Kiæb| Zv‡`i Zvovû‡ov Kiv‡eb bv| ◆ m¤¢ve¨ AvNvZg~jK NUbv* Av‡jvPbv ev eY©bv Kivi Rb¨ e¨w³†K Pvc w`‡eb bv hw` Zviv ej‡Z B”QzK bv nq| mnRfv‡e Zv‡`i Avcwb ejyb †h Avcwb †kvbvi Rb¨ Av‡Qb| ◆ wkï‡`i Avivg Abyfe Kivi Rb¨ Av‡iv mgq jvM‡Z cv‡i| Zviv eyS‡Z cv‡i Ggb kã e¨envi Kiæb| wkï‡`i mv‡_ m¤úK© ‰Zwi‡Z Zv‡`i AvMÖ‡ni wRwbm †bqvi cÖ‡qvRb n‡Z cv‡i (†Ljbv, eÜz, we`¨vjq BZ¨vw`)| » ¯úó I mswÿß ejyb ◆ e¨w³i cwiwPZ fvlv e¨envi Kiæb| †UKwbK¨vj c`¸‡jvi e¨envi Gwo‡q Pjyb| ◆ gvbwmK Pvc Z_¨ †evSvi ÿgZv‡K n«vm Ki‡Z cv‡i| gvbylwU‡K hv e‡j‡Qb Zv †evSvi Rb¨ Ab¨ wel‡q hvevi Av‡M GKwU mg‡q GKwU wel‡q K_v ejyb| ◆ g~j e³e¨ mswÿß Kiæb I cybivq ejyb| †h e¨w³ ev mvnvh¨ cÖv_x©‡K ¸iæZ¡c~Y© c‡q›U¸‡jv wjL‡Z ejv, GwU Zvi Rb¨ mnvqK n‡Z cv‡i| weKí e¨w³i Rb¨ g~j e³‡e¨i GKwU mvims‡ÿc w`b| » gvbyl hLb KwVb AwfÁZvi K_v cÖKvk K‡i, ZLb ms‡e`bkxjZvi mv‡_ cÖwZwµqv †`Lvb (†hgb- †hŠb wbh©vZb, mwnsmZv ev ¯-^ÿwZ) ◆ e¨w³‡K Rvbvb †h Avcwb Z_¨ †Mvcb ivLvi wel‡q m‡PZb| ◆ e¨w³i Abyf~wZ ev ag©vbyf~wZ‡K KLbI †QvU K‡i †`Lv ev wePvi we‡køl‡Yi gy‡LvgywL bv Kiv| ◆ e¨w³i Rb¨ fvMvfvwM Kiv KóKi welq¸‡jvi w`‡K jÿ¨ ivLyb| ◆ Ab¨ †mevq cvVv‡bv cÖ‡qvRb n‡j cwi®‹vifv‡e eY©bv Kiæb Zvi Rb¨ cieZ©x c`‡ÿc wK n‡e| Zv‡`i mvnv‡h¨i Rb¨ Ab¨ †mevcÖ`vbKvix‡`i mv‡_ Z_¨ cÖKvk Ki‡Z n‡j e¨w³i AbygwZ wbb| D`vniY ¯^iƒc: ▸Avcwb Avgv‡K e‡j‡Qb †h, Avcbvi cÖwZ‡ekx Avcbvi mv‡_ Lvivc AvPiY K‡i‡Q| Avwg Ab¨ Kv‡iv mv‡_ GUv †kqvi Ki‡ev bv, wKš‘ Avwg wKQz gvby‡li K_v fve‡Z cvwi, hviv nq‡Zv Avcbv‡K mvnvh¨ Ki‡Z cv‡i| GUv wK wVK Av‡Q †h Avwg K G‡RwÝi Avgvi mnKg©xi mv‡_ Avcbvi AwfÁZvwU Av‡jvPbv Kie? » gvbyl‡K Zv‡`i AvPiY Øviv wePvi Ki‡eb bv| ◆ ¸iæZi MNS Ae¯’vq gvbyl A¯^vfvweK AvPiY †`Lv‡Z cv‡i| eyS‡Z n‡e †h GwU Zv‡`i Amy¯’Zvi Rb¨| kvšÍ Ges axiw¯’i _vKzb| e¨w³‡K wb‡q KLbI Dcnvm Ki‡eb bv| ▸ hw` e¨w³ h_vh_fv‡e AvPiY bv K‡ib (†hgb:Aw¯’iZv, AvMÖvmx, ûgwK), mgm¨vi Drm mÜvb Kiæb Ges mgvav‡bi cigk© w`b| Zv‡`i hZœKvix‡`i Ges Ab¨ Kg©x m`m¨‡`i kvšÍ, Avivg`vqK ¯’vb ˆZwii Rb¨ AšÍfy ©³ Kiæb| hw` Zviv AZ¨šÍ D‡ØMRbK ev D‡ËwRZ nq, Zvn‡j Avcbv‡K Zv‡`i civgk© AMÖvwaKvi w`‡Z n‡e Ges Zv‡`i‡K GKevi Avcbvi civgk© ¯’v‡b wb‡q Avmyb| » cÖ‡qvR‡b †`vfvlx e¨envi Kiæb| ◆ cÖ‡qvR‡b, cÖwkwÿZ †`vfvlxi mv‡_ KvR Kivi †Póv Kiæb, m¤¢e n‡j MNS Ae¯’vq _vKv e¨w³i mv‡_ GKB wj‡½i †`vfvlx e¨envi Kiæb| hw` cÖwkwÿZ †`vfvlx cvIqv bv hvq, e¨w³ m¤§wZ wb‡q Ab¨ ¯^v¯’¨ †mevcÖ`vbKvix ev e¨w³i hZœKvix fvlvšÍi K‡i w`‡Z cv‡i| ◆ †hLv‡b hZœKvix fvlvšÍi K‡i w`‡”Qb Ggb cwiw¯’wZ‡Z mZK© _v‡K n‡e †h MNS Ae¯’vq _vKv e¨w³ cy‡ivcywi cÖKvk bvI Ki‡Z cv‡ib| Dciš‘,e¨w³ Ges hZœKvixi g‡a¨ AvMÖ‡ni Ø›Ø †hvMv‡hv‡M evavMÖ¯’ Ki‡Z cv‡i| hw` GwU GKwU welq nq Zvn‡j cieZ©x wfwR‡Ui Rb¨ Dchy³ `vfvlxi e¨e¯’v Kiæb| GPC 11 2. A¨v‡mm‡g›U bxwZgvjv wK¬wbK¨vj A¨v‡mm‡g›U GgGbGm Ae¯’v mbv³Ki‡Yi cvkvcvwk mgm¨v m¤c‡K© e¨w³i wbR¯^ aviYvI AšÍfz©³| e¨w³i kw³ I m¤c`¸‡jvi g~j¨vqb KivI ¸iæZ¡c~Y© (†hgb mvgvwRK mnvqZv)| GB AwZwi³ Z_¨ ¯^v¯’¨‡mev `vbKvix‡`i fvj †mev w`‡Z mvnvh¨ Ki‡e| A¨v‡mm‡g›U PjvKv‡j GgGbGm Ae¯’vi m‡½ mg¯Í †Pnviv, †gRvR, gy‡Li Awfe¨w³, kvixwiK fvlv I e¨w³i e³‡e¨i cÖwZ memgq g‡bv‡hvM †`Iqv ¸iæZ¡c~Y©| G P C » eZ©gvb Awf‡hvM AbymÜvb Kiæb ◆ wK Avcbv‡K GLv‡b wb‡q Gj? KLb I wKfv‡e mgm¨vwU ïiæ n‡qwQj? wKfv‡e GwU mg†qi mv‡_ cwiewZ©Z n‡q‡Q? ◆ GB mgm¨v m¤c‡K© Avcwb wK g‡b K‡ib? GUv †Kv_v †_‡K G‡m‡Q e‡j g‡b K‡ib? ◆ wKfv‡e GB mgm¨v Avcbvi ˆ`bw›`b Rxe‡bi Dci cÖfve †d‡j? ˆ`wbK KwgDwbwU Rxe‡b, ¯‹z‡j ev Kv‡R Avcbvi mgm¨vwU wKfv‡e cÖfve †d‡j? ◆ Avcwb GB ai‡bi mgm¨vi mgvavb Kivi Rb¨ wK †Póv K‡iwQ‡jb? Avcwb †Kvb Jla †Póv K‡i‡Qb? hw` K‡i _v‡Kb, wK ai‡bi (†hgb, wba©vwiZ, Awba©vwiZ, †flR)? GUvi wK cÖfve wQj? » GgGbGm Ae¯’vi m¤¢ve¨ cvwievwiK BwZnvm mÜvb Kiæb ◆ Avcbvi cwiev‡ii Kv‡iv G ai‡bi mgm¨v Av‡Q? » e¨w³i mvaviY ¯^v‡¯’¨i BwZnvm mÜvb Kiæb ◆ †KvbI c~e©eZ©x kvixwiK mgm¨v m¤c‡K© wRÁvmv Kiæbt ▸ Avcbvi AZx‡Z †Kvb ¸iæZi ¯^v¯’¨ mgm¨v wQj? ▸ Avcbvi †Kvb ¯^v¯’¨ mgm¨v Av‡Q, hvi Rb¨ eZ©gv‡b Avcwb †mev MÖnY Ki‡Qb? ◆ e¨w³ †KvbI Jla MÖnY Ki‡Qb wK-bv wRÁvmv Kiæb: ▸ ¯^v¯’¨ †mev`vbKvix KZ©„K wba©vwiZ Ggb †KvbI Ilya Av‡Q hv Avcbv‡K GLbB MÖnY Kivi K_v? ▸ Jl‡ai bvg wK? Avcwb wK †mUv wb‡q G‡m†Qb? Avcwb KZevi GwU MÖnY K‡ib? ◆ wRÁvmv Kiæb †h IB e¨w³i KLbI Ily‡a GjvwR©i cÖwZwµqv n‡q‡Q wKbv| » eZ©gvb Pvc, Lvc LvIqv‡bvi †KŠkj Ges mvgvwRK mg_©b A‡š^lY ◆ [†h NUbvi d‡j gvbweK m¼U m„wó n‡q‡Q, Zv D‡jøL Kiæb] ... Gi ci wKfv‡e Avcbvi Rxe‡b cwieZ©b G‡m‡Q? ◆ Avcwb wcÖqRb nvwi‡q‡Qb? ◆ Avcbvi Rxe‡b Pvc KZUv ¸iæZi? wKfv‡e GUv Avcbv‡K ÿwZ Ki‡Q? ◆ GLb Avcbvi me‡P‡q ¸iæZi mgm¨v¸‡jv wK? ◆ wKfv‡e Avcwb GB mgm¨v w`‡bi ci w`b †gvKv‡ejv Ki‡Qb? ◆ Avcbvi †Kvb ai‡bi mg_©b Av‡Q? Avcwb cwievi, eÜy ev m¤cÖ`v‡qi †jvK‡`i mvnvh¨ cvb? » m¤¢ve¨ A¨vj‡Kvnj I gv`K`ª‡e¨i e¨envi AbymÜvb Kiæb A¨vj‡Kvnj I Ilya msµvšÍ cÖkœ¸‡jv ms‡e`bkxj I A‡kvfbI e‡U| wKš‘ GwU GgGbGm g~j¨vq‡bi Acwinvh© Dcv`vb| e¨w³wU‡K e¨vL¨v Kiæb †h, GwU g~j¨vq‡bi Ask Ges bbRvR‡g›Uvj I mvs¯‹…wZK ms‡e`bkxjZvi mv‡_ cÖkœ wRÁvmvi †Póv Kiæb| ◆ A¨v‡mm‡g‡›Ui Ask wn‡m‡e Avwg Avcbv‡K wKQz iæwUb cÖkœ wRÁvmv Ki‡ev| Avcwb wK A¨vj‡Kvnj MÖnY K‡ib (ev Ab¨ †Kv‡bv c`v_©, hv GjvKvi mgm¨v e‡j cwiwPZ)? [hw` n¨v nqu] KZevi, w`b / mßv†n? ◆ Avcwb hLb Zxeª Pv‡c _v‡Kb, wei³ ev fxZ g‡b K‡ib, ZLb Avcwb †KvbI U¨ve‡jU Lvb? hLb e¨_v nq, ZLb Avcbvi e¨envi Kivi wKQz Av‡Q? Avcwb Ny‡gi U¨ve‡jU Lvb ? [hw` n¨vu nq] cÖwZw`b/mßv‡n Avcwb KZUv wb‡q‡Qb? KLb †_‡K? » m¤¢ve¨ AvZ¥NvZx wPšÍv I AvZ¥nZ¨vi †Póv AbymÜvb Kiæb AvZ¥nZ¨v msµvšÍ cÖkœ¸‡jvI AvµgYvZ¥K e‡j g‡b Kiv †h‡Z cv‡i, Z‡e GgGbGm A¨v‡mm‡g‡›Ui †¶‡Î GwUI ¸iæZ¡c~Y© cÖkœ| mvs¯‹…wZK ms‡e`bkxjZv I bbRvR‡g›Uvj Dcv‡q Rvbvi †Póv Kiæb| ◆ Avcwb ïiæ Ki‡Z cv‡ib Gfv‡e: fwel¨‡Zi Rb¨ Avcbvi Avkv wK? hw` e¨w³ nZvkv cÖKvk K‡ib, AviI cÖkœ wRÁvmv Kiæb (>> SUI gwWDj Gi e· 1), †hgb, Avcwb wK g‡b K‡ib †h, Rxeb evm‡hvM¨? Avcwb wK wb‡R‡K AvNvZ Kivi K_v g‡b K‡ib? ev Avcwb Avcbvi Rxeb †kl Kivi †Kvb cwiKíbv Av‡Q wK? (>> SUI) » GKwU j¶¨c~Y© kvixwiK cix¶v cwiPvjbv Kiæb ◆ GwU GKwU †K›`ªxf~Z kvixwiK cix¶v nIqv DwPZ, hv GgGbGm A¨v‡mm‡g‡›Ui mgq cvIqv Z_¨ Abyhvqx cwiPvwjZ| GB ch©v‡q †Kvb kvixwiK Ae¯’v cvIqv †M‡j, nq h_vh_ e¨e¯’v Kiæb bv nq h_vh_ KZ©…c‡¶i Kv‡Q †idvi Kiæb| » GKwU GgGbGm cwiw¯’wZ m‡›`n n‡j, g~j¨vq‡bi Rb¨ cÖvmw½K gwWDj hvb| » hw` e¨w³wU GKvwaK GgGbGm Ae¯’vi mv‡_ cÖvmw½K ˆewkó¨ Dc¯’vcb K‡i, Zvn‡j mg¯Í cÖvmw½K gwWDj¸‡jv we‡ePbv Kiv cÖ‡qvRb| 3. e¨e¯’vcbvi bxwZgvjv A‡bK GgGbGm Ae¯’v Zxeª n‡j `xN©‡gqv`x ch©‡e¶Y I d‡jv-Avc cÖ‡qvRb| gvbweK cwiw¯’wZ‡Z †mevi avivevwnKZv iÿv Kiv KwVb n‡Z cv‡i, KviY gvbwmK ¯^v¯’¨ †mev memgq mnRjf¨ bq ev gvbyl¸‡jv ¯’vbvšÍwiZ n‡e A_ev n‡q †M‡Q| AZGe, g~j¨evb m¤c` wn‡m‡e GgGbG‡mi Ae¯’vi mwnZ RbM‡Yi hZœkxj e¨w³‡`i wPwýZ Kiv ¸iæZ¡c~Y©| Zviv m¼U Ry‡o µgvMZ hZœ, mg_©b I ch©‡e¶Y cÖ`vb Ki‡Z m¶g n‡Z cv‡i| †mev`vbKvix‡`i g‡a¨ Ggb †KD Av‡Qb hv‡K cwievi, eÜy ev Ab¨ wek¦¯Í e¨w³‡`i mv‡_ GgGbG‡mi Ae¯’v mn e¨w³i my¯’Zvi Rb¨ `vwqZ¡ wb‡Z n‡e| GgGbGm Ae¯’v, e¨e¯’vcbv cwiKíbv Ges d‡jv-Avc Gi e¨vcv‡i e¨w³ Ges hZœkx‡ji eyS‡Z cviv e„w× Ki‡e| » GgGbGm Ae¯’vq e¨w³i gvbwmK I kvixwiK DfqB Ae¯’vi e¨e¯’vcbv Kiæb ◆ e¨w³i Ae¯’v m¤c‡K© Z_¨ cÖ`vb Kiæb ▸ hw` e¨w³ m¤§Z nb, Zvn‡j hZœKvix‡`i‡K Z_¨ mieivn Kiæb| ◆ AR©b†hvM¨ j¶¨ wba©vi‡Y Av‡jvPbv K‡i wVK Kiæb, Ges e¨w³i mv‡_ wg‡j e¨e¯’vcbv cwiKíbv ˆZwi Kiæb Ges GKgZ †nvb| ▸ hw` e¨w³ m¤§Z nb, Z‡e GB e¨vcv‡i Av‡jvPbvq hZœKvix‡`i AšÍfz©³ Kiæb| ▸ cÖ¯ ÍvweZ e¨e¯’vcbv cwiKíbvi †ÿ‡Î Z_¨ mieivn Kiæb: ∙ wPwKrmvi cÖZ¨vwkZ myweav; ∙ wPwKrmvi mgqKvj; ∙ wPwKrmv Pvwj‡q hvIqvi ¸iæZ¡, Gi g‡a¨ i‡q‡Q evmvq mswkøó gvbwmK wPwKrmv Abykxjb ( †hgb, wkw_jKib cÖwk¶Y) Ges hZœKvixiv wKfv‡e mvnvh¨ Ki‡Z cv‡ib; ∙ wba©vwiZ †Kvb Jl‡ai m¤¢ve¨ cvk¦© cÖwZwµqv ∙ mvgvwRK Kg©x, gvgjv cwiPvjK, KwgDwbwU ¯^v¯’¨Kg©x ev Ab¨ wek¦¯ Í m`m¨‡`i m¤¢ve¨ AskMÖnY (>>Pvc Kgv‡bv Ges mvgvwRK mnvqZv evov‡bvi bxwZ¸‡jv wb¤œiƒc); ∙ c~e©vfvm| Avkvev`x ¯^i eRvq ivLv, wKš‘ †m‡i IVv wb‡q ev¯Íeev`x †nvb| ◆ hw` cÖvmw½K nq, e¨e¯’vcbv cwiKíbvi Avw_©K w`K m¤c‡K© Z_¨ w`b| » e¨e ’¯vcbv cwiKíbv m¤c‡K© e¨w³ I Gi hZœKvixi cÖkœ I D‡Ø‡M mvov w`b » e¨w³ P‡j hvIqvi Av‡M: ◆ wbwðZ Kiæb †h e¨w³ I †mev`vbKvix e¨e¯’vcbv cwiKíbv eyS‡Z †c‡i‡Qb Ges GKgZ ( †hgb, Avcwb cwiKíbvwUi ¸iæZ¡c~Y© w`K¸‡jv cybive„wË Ki‡Z Dfq‡K ej‡Z cv‡ib)| ◆ j¶Y¸‡jvi ¯-^ch©‡e¶Y‡K DrmvwnZ Kiv Ges KLb Zvr¶wYK †mev w`‡Z ev wb‡Z n‡e, †m m¤ú‡K© e¨w³ I †mev`vbKvix‡K Rvbvb| ◆ GKwU d‡jv-Avc mv¶v‡Zi e¨e¯’v Kiæb| ▸ eZ©gvb gvbweK cwiw¯’wZ we‡ePbv K‡i GKwU d‡jv-Avc cwiKíbv ˆZwi Kiæb ( †hgb, cvwj‡q hvIqv/ ¯’vbvšÍwiZ RbmsL¨v Ges cwi‡lev¸‡jvi evav)| ▸ e¨w³ hw` GKB wK¬wb‡K Avm‡Z m¶g bv nbt ∙ GKwU msw¶ß wjwLZ e¨e¯’vcbv cwiKíbv w`b Ges e¨w³‡K fwel¨‡Z †h †KvbI wK¬wb‡K †h‡Z Zv m‡½ wb‡Z DrmvwnZ Kiæb| ∙ wbKU ’¯ ¯v^¯’¨ †mev †K‡› ª` †hvMv‡hv‡Mi Z_¨ w`b| ◆ j¶Y¸‡jv‡Z wPwKrmvi cÖwZwµqv bv Avmv ch©šÍ cÖv_wgK mvÿvZ¸‡jv NbNb Kivb| ◆ hLb j¶Y¸‡jvi DbœwZ n‡e, mvÿvZ Kg NbNb wKš‘ wbqwgZ n‡Z n‡e| ◆ e¨vL¨v Kiæb †h, d‡jvAvc wfwRU¸‡jvi g‡a¨ †h †Kvb mgq wK¬wb‡K wd‡i Avm‡Z cv‡ib, hw` cÖ‡qvRb nq (†hgb, Jl‡ai cvk¦© cÖwZwµqv n‡j) » cÖ‡Z¨K d‡jvAvc wfwR‡U g~j¨vqb Kiæb: ◆ wPwKrmvi cÖwZwµqv, Jl‡ai cvk¦© cÖwZwµqv Ges wbqwgZ Jla LvIqv Ges g‡bvmvgvwRK wPwKrmv| mKj DbœwZ jÿ¨ Abyhvqx n‡”Q e‡j ¯^xKvi Kiæb Ges wPwKrmv Pvwj‡q hvIqvi Dci Avev‡iv †Rvi w`b| ◆ mvaviY wPwKrmvi Ae¯’v| wbqwgZ kvixwiK ¯^v¯’¨ ch©‡eÿY Kiæb| ◆ wb‡Ri hZœ †bqv (†hgb, Wv‡qU, cwi”QbœZv, †cvlvK) Ges e¨w³i wb‡Ri cwi‡e‡k KvR Kiv| ◆ g‡bvmvgvwRK welq Ges/A_ev RxebhvÎvq cwieZ©b Avbv, hv e¨e¯’vcbvq f‚wgKv ivL‡Z cv‡i| ◆ wPwKrmvq e¨w³ I †mevKvixi †evSveywS I cÖZ¨vkv| fzj aviYv ïa‡i w`b| ◆ memgq †hvMv‡hv‡Mi me©‡kl Z_¨ hvPvB Kiæb, hw` NbNb cwiewZ©Z nq| » d‡jvAv‡ci cy‡ivUv mg‡qt ◆ e¨w³ I †mevKvixi mv‡_ wbqwgZ †hvMv‡hvM iÿv Kiæb| hw` m¤¢e nq, †Kvb KwgDwbwU Kg©x ev Ab¨ †Kvb wek¦¯Í KvD‡K IB e¨w³i ms¯ú‡k© _vK‡Z wbhy³ Kiæb| GB e¨w³ n‡Z cv‡ib Zvi cwiev‡ii m`m¨| ◆ e¨w³‡K †`Lv bv †M‡j ZLbKvi Rb¨ Kg© cwiKíbv wb‡q ivLyb| ▸ e¨w³ †Kb wd‡i Av‡mwb, Zv Luy‡R †ei Kivi †Póv Kiæb| KwgDwbwU Kg©x A_ev Ab¨ †Kvb wek¦¯Í †KD IB e¨w³i Ae¯’vb Rvbv‡Z cv‡i (†hgb, evwo‡Z hvIqv) ▸ hw` m¤¢e nq, e¨w³ hv‡Z wK¬wb‡K wd‡i Avm‡Z cv‡i, †mRb¨ Bmy¨ mgvav‡bi †Póv Kiæb| ◆ e¨w³i hw` DbœwZ bv nq, we‡kl‡Ái civgk© wbb| e¨w³ hw` Mf©eZx ev ¯Íb¨`vbKvix nb: » M‡f©i mšÍv‡bi Rb¨ m¤¢ve¨ SzuwKc~Y© Ilya †`qv †_‡K weiZ _vKzb, Ges Mf©Kvjxb †mev jv‡fi my‡hvM w`b » ey‡Ki y`a LvIqv‡”Qb Ggb gwnjvi ev”Pvi Rb¨ m¤¢ve¨ SzuwKc~Y© Jla †`qv Gwo‡q Pjyb| ey‡Ki y`a LvIqvb Ggb gwnjv whwb Ilya Lv‡”Qb, Zvui wkï‡K ch©‡e¶Y Kiæb| wkï evÜe ¯’vb/Zvey we‡ePbv Kiæb| 13 4. Pvc Kgv‡bv I mvgvwRK mnvqZv evov‡bvi bxwZgvjv Pvc Kgv‡bv I mvgvwRK mnvqZv evov‡bv gvbweK cwiw¯’wZ‡Z GgGbGm wPwKrmvi GKwU Awe‡”Q`¨ Ask, †hLv‡b gvbyl cÖvqB AwZwi³ gvbwmK Pv‡c _v‡K| G‡Z †Kej GgGbGm Ae¯’vq gvby‡li gvbwmK Pvc AšÍfz©³ bq, eis Zv‡`i †mevKvix I wbf©ikxj‡`i PvcI Gi AšÍfy©³| we`¨gvb GgGbGm Ae¯’v gvbwmK Pv‡c cÖvqB Ae`vb iv‡L ev Zv Av‡iv Lviv‡ci w`‡K wb‡q hvq| mvgvwRK mnvqZv Pv‡ci A‡bK ÿwZKi cÖfve Kgv‡Z cv‡i; AZGe, mvgvwRK mnvqZvq g‡bv‡hvM †`qv Acwinvh©| mvgvwRK mnvqZv kw³kvjx KivI myi¶v (>> gvbevwaKvi myi¶v bxwZ) Ges gvbweK msKU Øviv cÖfvweZ RbmsL¨vi mvgwMÖK fvj _vKvi †ÿ‡Î (>> mvgwMÖKfv‡e fv‡jv _vKvi †ÿ‡Î g‡bv‡hv‡Mi bxwZ) GKwU Acwinvh© Dcv`vb| » m¤¢ve¨ gvbwmK Pvc I mvgvwRK mnvqZvi mnRjf¨Zvi AbymÜvb ◆ GB w`b¸‡jv‡Z Avcbvi me‡P‡q eo D‡ØM wK? ◆ wKfv‡e Avcwb GB D‡ØM †gvKv‡ejv Ki‡eb? ◆ †Kvb †Kvb wRwbm hv Avcbv‡K ¯^w¯Í †`q I kw³ †hvMvq? ◆ Avcbvi mgm¨v¸‡jv †kqvi Ki‡Z Kv‡K me‡P‡q ¯^w¯Í`vqK g‡b K‡ib? hLb Avcwb fvj †eva K‡ib bv? hLb Avcwb fvj †eva K‡ib bv, mvnvh¨ ev civg‡k©i Rb¨ Kvi Kv‡Q hvb? ◆ Avcbvi cwiev‡ii mv‡_ Avcbvi m¤cK© †Kgb? wKfv‡e Avcbvi cwievi I eÜyiv Avcbv‡K mg_©b K‡i Ges Zv‡`i Øviv Avcwb wKfv‡e gvbwmK Pv‡c c‡ob? » wbh©vZb ev Ae‡njvi jÿY m¤c‡K© mRvM _vKzb ◆ bvix, wkï I eq¯‹ e¨w³i †hŠb I kvixwiK wbh©vZ‡bi (cvwievwiK mwnsmZvmn) m¤¢ve¨ j¶Y¸‡jvi e¨vcv‡i g‡bv‡hvMx †nvb (†hgb, AbvKvw•ÿZ ¶Z ev AvNvZ, AZ¨waK fq, cvwievwiK m`m¨ Dcw¯’Z _vK‡j welq¸‡jv wb‡q Av‡jvPbv Ki‡Z Awb”QzK)| ◆ Ae‡njvi m¤¢ve¨ j¶Y, we‡klZt wkï‡`i, A¶gZvi mv‡_ emevmKvix Ges eq¯‹ e¨w³‡`i cÖwZ ( †hgb, h‡_ó Lv`¨vfv‡e †Kvb cwiev‡i Acywó, GKwU wkï †h wb‡R‡K AwZwi³ ¸wU‡q wb‡q‡Q) g‡bv‡hvMx †nvb| ◆ hLb wbh©vZb ev Ae‡njvi wPý Dcw¯’Z, ¶wZKi wKQz NU‡Q wK-bv, Zv Rvb‡Z wbwiwewj ¯’v‡b e¨w³†K wRÁvmv Kiæb| ◆ Avcwb hw` wbh©vZb ev Ae‡njv m‡›`n K‡ib: ▸ Kg© cwiKíbv wb‡q Av‡jvPbvi Rb¨ Awej‡¤^ Avcbvi mycvifvBRv‡ii mv‡_ K_v ejyb| ▸ e¨w³i m¤§wZ wb‡q myi¶vi Rb¨ KwgDwbwUi m¤c` (†hgb, wek¦¯Í AvBwb cwi‡lev I myi¶v †bUIqvK©) mbv³ Kiæb| » msM„nxZ Z‡_¨i wfwˇZ wb¤œwjwLZ †KŠkj we‡ePbv Kiæb: ◆ mgm¨vi mgvavb: ▸ cÖavb cÖavb gvbwmK Pvc †gvKv‡ejvq e¨w³‡K mvnvh¨ Kivi Rb¨ mgm¨v mgvav‡bi †KŠkj e¨envi Kiæb *| gvbwmK Pvc¸‡jvi mgvavb ev Kgv‡bv bv †M‡j Zv gvwb‡q †bqvi Dcvq mbv³ Ki‡Z mgm¨v mgvav‡bi †KŠkj¸‡jv e¨envi Kiv †h‡Z cv‡i| mvaviYfv‡e, mivmwi civgk© †`‡eb bv| wb‡Ri mgvavb wb‡R‡KB †ei Ki‡Z e¨w³‡K Drmvn w`b| ▸ wkï I wK‡kvi-wK‡kvix‡`i mv‡_ KvR Kivi mgq, hZœKvix‡`i gvbwmK Pv‡ci KviY¸‡jv Rvbv Ges g~j¨vqb Kiv Acwinvh©| ◆ mvgvwRK mnvqZv kw³kvjx Kiæb: ▸ mnvqK I wek¦¯Í cvwievwiK m`m¨, eÜy I KwgDwbwUi m`m¨‡`i wPwýZ Ki‡Z Ges wKfv‡e G‡K Aci‡K mvnv‡h¨i K_v fve‡Z e¨w³‡K mvnvh¨ Kiæb| ▸ e¨w³i m¤§wZ wb‡q mvgvwRK mnvqZvi Rb¨ Ab¨vb¨ m¤cÖ`v‡qi m¤c`¸‡jvi K_v Zv‡`i D‡jøL Kiæb| mgvR Kg©x, †Km g¨v‡bRvi ev KwgDwbwU Ab¨ wek¦¯Í †KD Dchy³ m¤ú`¸‡jvi mv‡_ e¨w³i ms‡hvM ¯’vc‡b mnvqZv Ki‡Z cv‡i| †hgbt ∙ mvgvwRK ev myi¶v †mev ∙ Avkªq, Lv`¨ I A-Lv`¨ `ªe¨ ∙ KwgDwbwU †K›`ªmg~n, AvZ¥-mnvqZv I mnvqZv †Mvôx ∙ Avq-Drcv`K Kvh©µg I Ab¨vb¨ KvwiMwi Kvh©µg ∙ AvbyôvwbK / AbvbyôvwbK wk¶v ∙ wkï-evÜe ¯’vb ev wkï-wK‡kvix‡`i Rb¨ Ab¨vb¨ KvVv‡gvMZ Kvh©µg| †idv‡ij ˆZwii mgq e¨w³i AskMÖn‡Y mnvqZv Kiæb (†hgb, Ae¯’vb wb‡ ©`k Kiæb, Acv‡iwUsGi mgq, †Uwj‡dvb b¤i^, BZ¨vw`) Ges e¨w³‡K GKwU msw¶ß †idv‡ij †bvU mieivn Kiæb| ◆ gvbwmK Pvc e¨e¯’vcbv †kLvb: ▸ wkw_j nIqvi Rb¨ BwZevPK Dcvq¸‡jv mbv³ I †ei Kiæb (†hgb, Mvb †kvbv, †Ljvayjv BZ¨vw`)| ▸ e¨w³ I hZœKvix‡`i mywbw`©ó gvbwmK Pvc e¨e¯’vcbv †KŠkj †kLvb (†hgb, k¦v‡mi e¨vqvg (>> e· wRwcwm 2))| ∙ wKQz cwiw¯’wZ‡Z Avcwb GKRb ¯^v¯’¨ Kg©xi Kv‡Q cvVv‡Z cv‡ib (†hgb, bvm© ev g‡bvmvgvwRK Kg©x) hviv GB †KŠkj¸‡jv †kLv‡Z cv‡ib| » hZœKvix‡`i gvbwmK Pvc †gvKv‡ejvq bRi w`b ◆ hZœKvix‡K wRÁvmv Kiæb: ▸ eZ©gvb Riæwi gvbweK cwiw¯’wZ‡Z GgGbGm Ae¯’vq e¨w³i cwiPh©vq `ywðšÍv I D‡ØM¸‡jv m¤ú‡K©; ▸ ev¯Íe P¨v‡jÄmg~n (†hgb, †mevKvix‡`i mgq, ¯^vaxbZv, UvKv); ▸ Ab¨vb¨ ˆ`bw›`b Kv‡Ri mÿgZv, †hgb, KwgDwbwUi Kg©Kv‡Ð KvR Kiv ev Ask †bqv; ▸ kvixwiK Aemv`; ▸ hZœKvix‡`i Rb¨ mnRjf¨ mvgvwRK mnvqZv: ∙ Avcwb hLb e¨w³‡K mvnvh¨ Ki‡Z cvi‡eb bv, ZLb Ab¨ †Kvb e¨w³ wK Av‡Qb whwb Avcbv‡K mvnvh¨ Ki‡Z cv‡ib (D`vniY¯^iƒc, hLb Avcwb Amy¯’ ev Lye K¬všÍ) ▸ gvbwmKfv‡e fv‡jv _vKv| hZœKvix‡K hw` msKUvcbœ ev Aw¯’i g‡b n‡j Zv‡`i GgGbGm Ae¯’vi g~j¨vqb Kiæb (†hgb, >> DEP, SUB) ◆ g~j¨vq‡bi ci hZœKvixi Pvwn`v I D‡ØM¸‡jv †gvKv‡ejvi †Póv Kiæb| GUv n‡Z cv‡i: ▸ Z_¨ †`qv; ▸ mswkøó KwgDwbwU cwi‡lev I mnvqZvmg~‡ni mv‡_ hZœKvix‡K mshy³ Kiv; ▸ Aemi hZœ wb‡q Av‡jvPbv| cÖavb †mevKvix wekÖvg ev Ab¨ ¸iæZ¡c~Y© Kv‡R _vK‡j cwiev‡ii Ab¨ †Kvb Dchy³ m`m¨ e¨w³i mvgwqK h‡Zœi `vwqZ¡ wb‡Z cv‡ib; ▸ mgm¨v mgvav‡bi Dc‡`k †`qv/ cÖe‡jg mjwfs †UKwbK&m * Ges gvbwmK Pvc e¨e¯’vcbv †kLv‡bv; ▸ †mevKvix KZ©„K mbv³K…Z †h †Kvb GgGbGm cwiw¯’wZ e¨e¯’vcbv, ◆ ¯^xKvi Kiæb †h, GgGbGm Ae¯’vq e¨w³i †mev Kiv gvbwmK Pv‡ci KvR, wKš‘ hZœKvix‡`i ejyb †h, KvRwU Pvwj‡q hvIqv ¸iæZ¡c~Y©| GgbwK hLb GwU Lye KwVb n‡q I‡V, e¨w³i gh©v`vi cÖwZ kÖ×v †`Lv‡bv †mevKvixi Rb¨ Riæwi Ges Zv‡`i wb‡R‡`i Rxeb wb‡q hZUzKz m¤¢e wm×všÍ wb‡Z hy³ Kiv| G P C G P C e· wRwcwm 1: KwgDwbwU mnvqZv evov‡bv wPwKrmv e¨e¯’vcbvi †ÿ‡Î †mBme Kv‡R Drmvn w`b hv mevi we‡kl K‡i KwgDwbwUi wcwQ‡q cov m`m¨‡`i Rb¨ cvwievwiK I KwgDwbwUi mn‡hvwMZv e„w× cvq| Av‡iv wb‡ ©`kbvi Rb¨ AvÛvi÷¨vwÛs KwgDwbwU-†eBRW †cÖv‡UKkb (UNHCR, 2013) Ges Riæwi Ae¯’vq gvbwmK ¯^v¯’¨ I g‡bvmvgvwRK mnvqZv wb‡q AvBGGmwm bxwZgvjvi A¨vKkb wkU 5.2 †`Lyb| e· wRwcwm 2: wij¨v‡·kb e¨vqvg: axi MwZi k¦vm cÖk¦v‡mi †KŠkj Avwg Avcbv‡K †kLv‡Z hvw”Q, wKfv‡e GKwU wbw` ©ó Dcv‡q k¦vm-cÖk¦vm Avcbvi kixi I gb wkw_j n‡Z mvnvh¨ Ki‡e| Avcwb GB k¦vm †KŠk‡ji c~Y© myweav Abyfe Kivi Av‡M wKQz Abykxjb Ki†Z n‡e| GB †KŠkjwU k¦v‡mi Dci g‡bv‡hvM †K›`ªxf‚Z K‡i KviY, hLb Avgv‡`i k¦vm `ªæZ Ges AMfxi n‡q I‡V, ZLb Avgv‡`i D‡ËRbv ïiæ nq| wkw_j Kiv ïiæ Kivi Rb¨, Avcbvi k¦vm‡K cwieZ©b K‡i ïiæ Ki‡Z n‡e| ïiæi Av‡M, Avgiv kixi wkw_j Kie| Avj‡Zvfv‡e Avcbvi nvZ I cvq SvuKvb Ges †Q‡o w`b| G¸‡jv‡K wX‡jXvjv Kiæb I †Q‡o w`b| Avcbvi Nvo †cQ‡b †divb Ges ax‡i ax‡i gv_vwU Gcvk †_‡K Icv‡k mivb| GLb GK nvZ Avcbvi †c‡Ui Ici Ges Ab¨ nvZ Avcbvi ey‡Ki Ici ivLyb| Avwg Avcbv‡K Kíbv Kiv‡Z PvB, Avcbvi †c‡U GKwU †ejyb Av‡Q, hLb Avcwb k¦vm wb‡”Qb, ZLb †hb Avcwb †ejyb dzwj‡q Dc‡i DVv‡”Qb, myZivs Avcbvi †cUwU dz‡j DV‡e| hLb Avcwb k¦vm †dj‡eb, ZLb †ejy‡bi evZvmI †ei n‡q hv‡e, Avcbvi †cUI mgvb n‡e| cÖ_‡g Avgv‡K †`Lyb, Avwg Avgvi †cU †_‡K me evZvm †ei Ki‡Z hvw”Q| [†cU †_‡K k¦vm cÖk¦vm †`Lvb, †Póv Kiæb Ges †c‡U evZvm XzKv‡bv I †ei Kiv evwo‡q †`Lvb] wVK Av‡Q, GLb Avcwb Avgvi mv‡_ Avcbvi †cU †_‡K k¦vm †djvi †Póv Kiæb| g‡b ivL‡eb, Avgiv me evqy †ei bv nIqv ch©šÍ wbtk¦vm †dj‡Z _vK‡ev; Zvici k¦vm wbb| hw` cv‡ib, †Póv Kiæb Ges wbtk¦vm wbb, Avcbvi bvK w`‡q k¦vm wbb I gyL w`‡q Qvo–b| `viæb n‡q‡Q! GLb wØZxq avc n‡jv Avcbvi k¦vm-cÖk¦v‡mi MwZ Kgv‡bv| ZvB Avgiv wZb †m‡KÛ a‡i k¦vm wbe, Zvici y`B †m‡KÛ k¦vm a‡i ivLe Ges wZb †m‡K‡Û k¦vm †ei K‡i w`e| Avwg Avcbvi mv‡_ ¸b‡ev| Avcwb PvB‡j †PvL eÜI ivL‡Z cv‡ib Avevi †LvjvI ivL†Z cv‡ib| wVK Av‡Q, wbtk¦vm wbB, 1, 2, 3, a‡i ivwL 1, 2 Ges †ei K‡i w`B 1,2,3| Avcwb wK †Lqvj K‡i‡Qb, Avwg wKfv‡e ax‡i ax‡i ¸‡bwQ? [cÖvq GK wgwbU a‡i wbtk¦v‡mi GB Abykxjb evievi Ki‡ev] wVK Av‡Q, hLb Avcwb wb‡R wb‡R †Póv Ki‡eb, wZb †m‡KÛ a‡i ivL‡Z n‡e, Gi cÖwZ Lye m‡PZb bv nIqv| hLb Avcwb gvbwmK Pv‡c _vK‡eb, ZLb m‡e ©v”P †Póv Kiæb wbtk¦v‡mi MwZ †hb axi _v‡K| wVK Av‡Q, GLb Avcwb wb‡RB †Póv Kiæb GK wgwbU a‡i| 15 5. gvbevwaKvi myi¶v bxwZgvjv ¸iæZi GgGbGm Ae¯’vq gvbevwaKvi j•N‡bi SzuwK‡Z _vKv gvbyl‡`i myi¶vi cÖ‡qvRb| Kg©‡¶Î, evm¯’vb I cvwievwiK Rxebmn wewfbœ †¶‡Î ˆel‡g¨i wkKvi nIqvi cvkvcvwk Zviv cÖvqB wb‡R‡`i I Zv‡`i cwiev‡ii hZœ †bIqvi †ÿ‡Î Amyweav †fvM K‡ib| gvbweK mvnvh¨ †c‡Z Zv‡`i Lye Kg cÖ‡ekvwaKvi _vK‡Z cv‡i| Zviv Zv‡`i wb‡R‡`i cwiev‡i wbh©vZb ev Ae‡njvi wkKvi n‡Z cv‡ib Ges cÖvqB KwgDwbwUi mv‡_ m¤c~Y©fv‡e Ask †bIqvi my‡hvM A¯^xKvi K‡i| ¸iæZi GgGbGm Ae¯’vq wKQz gvbyl m‡PZb bvI _vK‡Z cv‡ib †h, Zv‡`i GKwU mgm¨v Av‡Q, †hLv‡b hZœ I mg_©b cÖ‡qvRb| GgGbGm Ae ’¯vq _vKv e¨w³‡`i Riæwi gvbweK cwiw¯’wZ‡Z †ek wKQz †ÿ‡Î gvbevwaKvi j•Nb n‡Z cv‡i, hvi g‡a¨ i‡q‡Q: » Lv`¨, cvwb, m¨vwb‡Ukb, Avkªq, ¯^v¯’¨‡mev, myi¶v Ges RxweKv mnvqZv, †hgb- †eu‡P _vKvi †gŠwjK Pvwn`v¸‡jv e¨env‡i ˆelg¨; » AvBwb m¶gZv PP©vi AwaKvi A¯^xKvi; » we‡kl Pvwn`vi cwi‡levq my‡hv‡Mi Afve; » kvixwiK I †hŠb wbh©vZb, †kvlY, mwnsmZv, Ae‡njv Ges B”QvK…Z AvUK » ¯’vbvšÍwiZ nIqvi mgq cwievi †_‡K we‡”Q` ev cwiZ¨³ nIqv; » cÖvwZôvwbK †mwUs‡m cwiZ¨vM I Ae‡njv `yf©vM¨ekZt, KwgDwbwU myi¶v e¨e¯’v I cÖwZeÜx Kg©m~wP¸‡jv‡Z ¸iæZi GgGbGm Ae¯’vq gvby‡li myi¶v me©`v AšÍfy©³ _v‡K bv, Ges KLbI KLbI Zv mwµqfv‡e ev` †`qv nq| G R‡b¨ GB me gvby‡li myi¶vi GB NvUwZ c~i‡Y Aek¨B ¯^v¯’¨‡mev cÖ`vbKvix‡`i mwµq mnvqZv w`‡Z n‡e| gvbweK cwiw¯’wZ‡Z KwgDwbwUi g‡a¨ GgGbGm Ae¯’vq _vKv gvby‡li myi¶vq cÖavb KvR¸‡jv wb‡P †`qv nj: » g~j Askx`vi‡`i RwoZ ivLyb ◆ g~j Askx`vi‡`i wPwýZ Kiæb, hviv Pvicv‡k GgGbGm Ae¯’vq _vKv †jvK‡`i myiÿv Bmy¨‡Z m‡PZb| GB g~j Askx`vi‡`i g‡a¨ i‡q‡Q: ▸ GgGbGm Ae¯’vi gvbyl I Zv‡`i hZœKvixiv; ▸ KwgDwbwUi †bZviv (†hgb, KwgDwbwUi wbe©vwPZ cÖwZwbwa, KwgDwbwUi eq¯‹iv, wk¶K, ag©xq †bZv, HwZn¨MZ I Ava¨vwZ¥K †meK; ▸ wewfbœ cwi‡lev cwiPvjKiv (†hgb, myi¶v / wbivcËv, ¯^v¯’¨, Avkªq, cvwb I m¨vwb‡Ukb, cywó, wk¶v, N‡ivqv Kg©m~wP); ▸ AÿgZv Kg©m~wPi cwiPvjKiv (GgGbGm Ae¯’vi Kvi‡Y A‡bK A¶gZv Kg©m~wP‡Z AÿgZvB AmveavbZvekZt D‡cw¶Z _v‡K); ▸ KwgDwbwU MÖæc¸‡jv (hyeK ev bvix `‡ji) Ges gvbevwaKvi ms¯’v¸‡jvi cÖwZwbwa; cywjk I AvBb KZ©…c¶ ◆ g~j Askx`vi‡`i Rb¨ m‡PZbZv e„w×i Kvh©µg msMwVZ Kiæb: ▸ GgGbGm Ae¯’vi Dci cwiwPwZg~jK Kg©kvjv we‡ePbv Kiæb| ▸ m‡PZbZv e„w×i Kvh©µg¸‡jvi cÖYqb I ev¯Íevq‡b GgGbGm Ae¯’vi gvbyl, Zv‡`i hZœKvix Ges A¶gZv I mgvR †mev Lv‡Zi †jvKR‡bi mv‡_ Av‡jvPbv Kiæb| ▸ m‡PZbZv e„w× Kvh©µg PjvKv‡j: ∙ GgGbGm Ae¯’vq _vKv gvbyl m¤ú‡K© fzj aviYv¸‡jv Rvbvb I `~i Kiæb| ∙ gvbweK mvnvh¨ I myi¶vq mgvb my‡hvMmn GgGbGm Ae¯’vi gvby‡li AwaKvi m¤ú‡K© Rvbvb| ∙ GgGbGm Ae ’¯vi gvby‡li weiæ‡× ˆelg¨ `~i Kiæb| ∙ GgGbGm Ae ’¯vi gvby‡li hZœKvix‡`i mnvqZvi Rb¨ cÖPviYv Pvjvb| » ¯^v¯’¨‡mev †mwUs‡m ¸iæZi GgGbGm Ae¯’vi gvby‡li AwaKvi i¶v Kiæb ◆ GgGbGm Ae¯’vi gvbyl‡K me©`v m¤§vb I gh©v`vi mv‡_ †`Lyb| ◆ GgGbGm Ae¯’vi gvbyl¸‡jv hv‡Z Ab¨‡`i g‡Zv GKB kvixwiK ¯^v¯’¨‡mev cvq, Zv wbwðZ Kiæb| ◆ GKRb e¨w³i ¯^v¯’¨‡mev cÖZ¨vL¨vb Kivi AwaKvi‡K m¤§vb †`Lvb, hw` bv IB e¨w³i wm×všÍ †bqvi ÿgZv Kg _v‡K| (wmGd. ¯^vÿwiZ AvšÍR©vwZK Pzw³) ◆ cÖvwZôvwbKxKiY‡K wbiærmvwnZ Kiæb| hw` †KD B‡Zvg‡a¨B cÖvwZôv‡b hy³ n‡q _v‡K, Z‡e cÖvwZôvwbK †mwUs‡m Zvi AwaKv‡ii Rb¨ cÖPviYv Pvjvb| » KwgDwbwUi ¸iæZi GgGbGm Ae¯’vi gvbyl¸‡jvi g‡a¨ mgš^q evovb ◆ Nv‡ivqv mnvqZv, myi¶v Kg©m~wP I KwgDwbwUi Ab¨vb¨ Kg©Kv‡Ð GgGbGm Ae¯’vi gvb yl¸‡jv‡K AšÍfy©³ Ki‡Z cÖPviYv Pvjvb| ◆ g~javivi wk¶v e¨e¯’vq g„Mx‡ivM I Ab¨vb¨ GgGbGm Ae¯’vi wkï‡`i AšÍfz©³ Ki‡Z mnvqZv Kiæb| ◆ KwgDwbwUi cÖwZeÜx mnvqZv Kg©m~wP‡Z eyw× cÖwZeÜx / wej‡¤^ e„w×i wkï I cÖvßeq¯‹‡`i AšÍfy©³ Ki‡Z mnvqZv Kiæb| ◆ hZ¶Y m¤¢e, GgGbGm Ae¯’vi gvby‡li Rb¨ ¯^vqZ¡kvmb I ¯^vaxbZv eRvq ivL‡Z mnvqZv Kiæb| gvbweK Kv‡R myi¶vi mvaviY bxwZgvjv wùqvi n¨vÛeyK (wùqvi cÖKí, 2011) G e¨vL¨v Kiv n‡q‡Q| gvbwmK nvmcvZvj / ms¯’vq myi¶v wb‡q AwZwi³ wb‡`©wkKv †c‡Z Ges Avc`Kvjxb cwiw¯’wZ‡Z gvbwmK ¯^v¯’¨ Ges g‡bvmvgvwRK mnvqZvi AvBGGmwm bxwZgvjvi (AvBGGmwm, 2007) A¨vKkb wkU 6.3 †`Lyb| 6. mvwe©Kfv‡e fv‡jv _vKvi w`‡K g‡bv‡hv‡Mi bxwZgvjv wPwKrmv †mev QvovI, GgGbGm Ae¯’vi gvby‡li mvwe©Kfv‡e fv‡jv ivL‡Z Zv‡`i Av‡iv A‡bK mnvqZv cÖ‡qvRb| we‡kl K‡i †gŠwjK cwi‡lev, mvgvwRK KvVv‡gv, cvwievwiK Rxeb I wbivcËv cÖvqB †h gvbweK cwiw¯’wZ‡Z evavcÖvß nq, †m‡ÿ‡Î GUv ev¯Íe| GgGbGm Ae¯’vi gvbyl Zv‡`i ˆ`bw›`b KvR I †gŠwjK AvZ¥‡mevq AwZwi³ P¨v‡j‡Äi gy‡L c‡ob| AvBGGmwm wb‡ ©`wkKvi wcivwgW (wPÎ wRwcwm 1 †`Lyb) Abyhvqx, GgGbG‡mi Ae¯’vi gvby‡li mvwe©K fv‡jv _vKvi Rb¨ wPwKrmv †mevi evB‡i wewfbœ †m±‡i cÖPviYv Pvjv‡Z ¯^v¯’¨‡mev cÖ`vbKvixi f‚wgKv e„w× cvq| » gh©v`vi mv‡_ †eu‡P _vKv I wU‡K _vKvi Rb¨ wbivc‡` cÖ‡qvRbxq cwi‡lev (†hgb- cvwb, m¨vwb‡Ukb, Lv`¨ mnvqZv, Avkªq, RxweKv mnvqZv) †c‡Z GgGbGm Ae ’¯vi gvbyl‡K mnvqZv Kiæb| Gi g‡a¨ i‡q‡Q: ◆ GB ai‡bi cwi‡levi cÖvc¨Zv I Ae¯’vb m¤c‡K© civgk© †`qv; ◆ mgvR †mevq gvbyl‡K hy³ Ki‡Z mvgvwRK LvZ‡K mwµqfv‡e wb‡ ©`k Kiv Ges KvR Kiv †hgb, mgvR K‡g©i g‡Zv †Km e¨e¯’vcbv); ◆ wbivcËvi ûgwK m¤c‡K© e¨w³ h‡_ó m‡PZb bv n‡j wbivcËvi welq¸‡jv wb‡q civgk© †`Iqv| » GgGbGm Ae¯’vi gvby‡li Rb¨ cÖvmw½K Kg©Kv‡Ð AMÖvwaKv‡ii my‡hvM m„wó Kiv, †hgb- GB Ae¯’vi wkï‡`i Rb¨ wkï-evÜe ¯’v‡bi e¨e¯’v Kiv| » GgGbGm Ae¯’vi gvby‡li mvaviY kvixwiK ¯^v‡¯’¨ mnvqZv w`b: ◆ wbqwgZ ¯^v¯’¨ cixÿv I wUKvi e¨e¯’v Kiæb| ◆ †gŠwjK AvZ¥‡mev m¤c‡K© civgk© w`b (cywó, kvixwiK KvR, wbivc` †hŠb AvPiY, cwievi cwiKíbv, BZ¨vw`)| D`vniY wK¬wbK¨vj gvbwmK ¯^v‡ ’¯¨i hZœ (wcGBPwm Kg©x‡`i Øviv ev gvbwmK ¯^v ’¯¨ †ckvRxex‡`i Øviv) wbw`©ó e¨w³ ev cwiev‡i †gŠwjK Av‡eMxq I ev ͯewfwËK mnvqZv mvgvwRK †bUIqvK©¸‡jv mwµq Kiv wkï-evÜe mnvqK ’¯vbmg~n fvj gvbweK Abykxj‡bi Rb¨ A¨vW‡fv‡Kwm t †gŠwjK †mevmg~n hv wbivc`, mvgvwRKfv‡e Dchy³ Ges hv gh©v`v i¶v K‡i| wK¬wbK¨vj †mevmg~n wbw`©ó g‡bvmvgvwRK mnvqZvmg~n KwgDwbwUI cwiev‡ii mnvqZv kw³kvjxKiY †gŠwjK †mevmg~n I wbivcËvq mvgvwRK we‡ePbv G P C wPÎ wRwcwm 1. Riæwi Ae ’¯vq AvBGGmwm B›Uvi‡fbkb wcivwgW gvbwmK ¯^v ’¯¨ Ges gb ͯvwË¡K mnvqZv (Aby‡gv`‡bi mv‡_ Awf‡hvwRZ) 17 Zxeª gvbwmK Pvc Riæwi gvbweK cwiw¯’wZ‡Z eq¯‹, wK‡kvi-wK‡kvix I wkïiv cÖvqB m¤¢ve¨ AvNv‡Zi NUbvi wkKvi nq *| G me NUbvq eo cwim‡i Av‡eMxq, wPšÍvi, AvPiYMZ I kvixwiK cÖwZwµqv †`Lv †`q| hw`I †ekxifvM cÖwZwµqv AvZ¥-wbqwš¿Z Ges gvbwmK †ivM ˆZwi K‡i bv, wKš‘ Zxeª cÖwZwµqvi gvbyl‡`i mvnv‡h¨i cÖ‡qvRb nq| eû Riæwi gvbweK cwiw¯’wZ‡Z gvbyl wewfbœ ai‡bi m¤¢ve¨ AvNvZ I ÿq¶wZ RwbZ mgm¨vq †fv‡M; Gfv‡e Zviv Zxeª gvbwmK Pvc I cÖPÐ †kvK `yÕwU‡ZB fzM‡Z cv‡i| Zxeª Pvc I cÖPÐ †kv‡Ki j¶Y, wbiƒcb I e¨e¯’vcbv LyeB mvaviY| hv‡nvK, cÖPÐ †kvK Ab¨ gwWD‡j eY©bv Kiv n‡q‡Q (>> GRI)| mv¤cÖwZK m¤¢ve¨ AvNv‡Zi NUbvi ci, wPwKrm‡Ki wb‡Pi welq¸wj mbv³ Kiv cÖ‡qvRb: » Zxeª gvbwmK Pv‡ci (GwmBD) ¸iæZ¡c~Y© jÿY GB me jÿ‡Yi gvby‡li g‡a¨ Awbw`©ó gvbwmK Ges e¨vL¨vnxb kvixwiK mgm¨v _v‡K| GB j¶Y¸wji g‡a¨ MZ GK gv‡mi g‡a¨ AvNvZg~jK NUbvi cÖwZwµqv AšÍfy©³, †h Kvi‡b gvbyl mvnvh¨ †Luv‡R A_ev hv ˆ`wbK Kv‡R h‡_ó Amyweavi m„wó K‡i, Ges hv GB MvB‡W AšÍfy©³ Ab¨ †Kvb Ae¯’vi mv‡_ †g‡j bv| eZ©gvb gwWD‡j Zxeª gvbwmK Pv‡ci D‡jøL‡hvM¨ j¶Y A¨v‡mm‡g›U I cwiPh©v/e¨e¯’vcbv wb‡q Av‡jvPbv Kiv n‡q‡Q| . » †cv÷ UªgvwUK †÷ªm wWmAW©vi (wcwUGmwW) hLb GKB ai‡bi DcmM©mg~n (cybtAwfÁZv, cwiZ¨vM I eZ©gvb ûgwK‡Z AwZwi³ Abyf‚wZ) m¤¢ve¨ AvNvZg~jK NUbvi ci GK gv‡mi †ewk mgq a‡i Pj‡Z _vK‡j Ges ˆ`wbK Kv‡R h‡_ó Amyweavi m„wó Ki‡j, e¨w³i †cv÷-UªgvwUK †÷ªm wWmAW©vi n‡Z cv‡i| » gvbwmK Pvcg~jK NUbv NUvi ci mgm¨v I †ivM nIqvi m¤¢vebv †ewk (†hgb- m¤¢ve¨ AvNvZg~jK NUbv), wKš‘ GB ai‡bi G·‡cvRv‡ii Abycw ’¯wZ‡ZI Zv n‡Z cv‡i| Gi g‡a¨ i‡q‡Q: gvSvwi-¸iæZi welYèZv (>> wWBwc), mvB‡Kvwmm (>> wcGmIqvB), A¨vj‡Kvnj Ges Ily‡ai ¶wZKviK e¨envi (>> GmBDwe), AvZ¥nZ¨v (>> GmBDAvB) Ges Ab¨vb¨ D‡jøL‡hvM¨ gvbwmK ¯^v¯’¨ mgm¨v (>> IwUGBP)| » †hme cÖwZwµqv wPwKrmvi Rb¨ D‡jøL‡hvM¨ bv Ges †h wPwKrmv ev cwiPh©vi cÖ‡qvRb nq bv| me cÖwZwµqvi g‡a¨ G¸‡jv me‡P‡q mvaviY| Gi g‡a¨ ¶Y¯’vqx cÖwZwµqv¸wjI i‡q‡Q, hvi Rb¨ gvbyl mvnvh¨ †Luv‡R bv Ges hv†Z w`‡bi ci w`b Kv‡R e¨vNvZ N‡U bv| Gme †¶‡Î, ¯^v¯’¨ mnvqZvKvix‡K mnvqK n‡Z n‡e, e¨w³i cÖZ¨vwkZ cÖ‡qvRb c~i‡Y mvnvh¨ Ki‡Z n‡e Ges m‡PZb I ch©‡eÿY Ki‡Z n‡e, KLb cÖvK…wZK mnvqZv Avm‡e| A C U 13 ACU 19 A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1: e¨w³ wK m¤cÖwZ m¤¢ve¨ AvNvZg~jK NUbvi wkKvi? » e¨w³ m¤¢ve¨ AvNvZg~jK NUbvi wkKvi wK-bv wRÁvmv Kiæb| GKwU m¤¢ve¨ AvNvZg~jK NUbv n‡jv kvixwiK ev †hŠb mwnsmZvi (cvwievwiK mwnsmZvmn) g‡Zv †KvbI ûgwK ev fq¼i NUbv, b„ksmZv ev eo y`N©Ubv ev AvnZ n‡Z †`Lv| wRÁvmv we‡ePbv Kiæb: ◆ Avcbvi cÖavb gvbwmK Pvc Kx? Avcbvi Rxeb wec‡`i gy‡L? Ggb wKQzi AwfÁZv wK Avcbvi Av‡Q, hv Lye fq¼i ev AvZ‡¼i, hv‡Z Avcbvi Lye Lvivc †j‡M‡Q? Avcwb evwo‡Z wK wbivc` †eva K‡ib? » NUbvi ci KZw`b cvi n‡q‡Q, wRÁvmv Kiæb| » hw` MZ gv‡mi g‡a¨ m¤¢ve¨ AvNvZg~jK NUbv N‡U, Zvn‡j A¨v‡mm‡g›U cÖkœ 2-G hvb| » hw` GKwU eo ¶wZ (†hgb, wcÖqR‡bi g„Zy¨) n‡q _v‡K, ZviciI Zxeª Kó g~j¨vqb Kiæb (>> GRI) » 1 gv‡miI Av‡M m¤¢ve¨ AvNvZg~jK NUbv N‡U, Zvn‡j GB wb‡ ©`wkKvi (wWBwc, wcwUGmwW, wcGmIqvB, GmBDwe) Ab¨ Ae¯’v¸‡jv we‡ePbv Kiæb| A¨v‡mm‡g›U cÖkœ 2: hw` MZ GK gv‡mi g‡a¨ m¤¢ve¨ AvNvZg~jK NUbv N‡U, Zvn‡j e¨w³i g‡a¨ Zxeª gvbwmK Pv‡ci D‡jøL‡hvM¨ j¶Y Av‡Q wK? » AbymÜvb Kiæb:  UªgvwUK NUbv m¤úwK©Z ûgwK wb‡q D‡ØM  Ny‡gi mgm¨v  g‡bv‡hv‡Mi mgm¨v  evievi fq¼i ¯^cœ †`Lv, d¬¨vke¨vK* ev NUbvi AbvûZ ¯§„wZi cybive„wË, hv Zxeª fq I AvZ‡¼i|  NUbvi mv‡_ hy³ _vKv e¨w³‡K g‡b c‡o hvq Ggb wPšÍv, ¯§„wZ, Kvh©Kjvc ev cwiw¯’wZ B”QvK…Z Gwo‡q Pjv (†hgb, NUbv g‡b covi g‡Zv welq¸wj m¤ú‡K© K_v ejv ev †hLv‡b NUbvwU N‡UwQ‡jv †mB GjvKvq †div Gwo‡q Pjv) ◆ ÒD‡ËwRZÓ ev ÒwLUwL‡UÓ nIqv; wec‡`i e¨vcv‡i AwZwi³ D‡ØM I mZK©Zv A_ev †Rv‡i nBPB‡qi k³ cÖwZwµqv Rvbv‡bv ev AcÖZ¨vwkZ bovPov|  K‡ói Abyf‚wZ, ¯Íw¤¢Z ev Amvo nIqv, A_ev wKQz †eva Ki‡Z A¶g  †h‡Kv‡bv weiw³Ki Av‡eM (†hgb, Nb Nb AkÖæ †djv, ivM) ev wPšÍv AvPi‡Yi cwieZ©b, †hgb: ▸ AvMÖvmx g‡bvfve ▸ mvgvwRK wew”QbœZv I ¸wU‡q †djv ▸ eqtmwÜKv‡j SuywKg~jK AvPiY ▸ cðv`Mvgx AvPiY* (eZ©gv‡bi †P‡q Kg eqmx‡`i g‡Zv AvPiY Kiv), †hgb- Ny‡gi g‡a¨ cÖ¯ ªve, AvoóZv, wkï‡`i g‡a¨ Kvbœv  nvBcvi‡fbwU‡jkb (†hgb, ª`æZ k¦vmcÖk¦vm, †QvU k¦vmcÖk¦vm)  wPwKrmv weÁv‡b e¨vL¨vnxb kvixwiK Awf‡hvM, †hgb: ▸ eyK aodovwb, gv_v Nyiv‡bv ▸ gv_v e¨v_v, e¨v_v ▸ kix‡ii mv‡_ wew”Qbœ †Kvb jÿY, (†hgb, wPwKrmv weÁv‡b e¨vL¨vnxb c¨vivjvBwmm, ej‡Z ev †`L‡Z bv cviv, ÒwmD‡WvwmRviÓ) » Zxeª gvbwmK Pv‡ci D‡jøL‡hvM¨ j¶Y wb‡Pi me¸‡jv µvB‡Uwiqvq wg‡j †M‡j e¨w³ m¤¢ve¨ gvbwmK Pv‡c:  AvbygvwbK 1 gv‡mi g‡a¨ GKwU m¤¢ve¨ AvNvZg~jK NUbv N‡U‡Q|  NUbvi c‡i j¶Y ïiæ nq| DcmM© ev j¶Y¸wji Kvi‡Y ˆ`wbK Kv‡R h‡_ó Amyweav nq A_ev jÿ‡Yi Rb¨ A‡b¨i mvnvh¨ †LuvRv A C U » gvbwmK, ¯øvqyweK I gv`K`ªe¨ e¨envi (GgGbGm) Ae¯’v (welYœZvmn) hw` cvIqv hvq, hv GB wb‡ ©`wkKvq ewY©Z, hv‡Z DcmM©¸wji e¨vL¨v †g‡j I e¨e¯’v †bqv hvq| A¨v‡mm‡g›U cÖkœ 3: GKB mg‡q msNwUZ Avi †Kvb Ae¯’v Av‡Q wK ? » DcmM©¸wji e¨vL¨v †`qv hvq I †mB Abyhvqx e¨e¯’v †bqv hvq, Ggb †Kvb kvixwiK Ae¯’v Av‡Q wK-bv hvPvB Kiæb| g~j wPwKrmv cwiKíbv Zxeª gvbwmK Pvc Dcm‡M©i e¨e¯’vcbvq Jla w`‡eb bv (hw` bv wb¤œwjwLZ e¨wZ‡i‡K nq)| 1. mg¯Í †¶‡Î: » †gŠwjK g‡bvmvgvwRK mnvqZv cÖ`vb Kiæb3  mveav‡b ïbyb| K_v ejvi Rb¨ e¨w³‡K Pvc †`‡eb bv|  e¨w³‡K Zvi Pvwn`v I D‡ØM m¤c‡K© wRÁvmv Kiæb|  e¨w³i †gŠwjK Pvwn`v †gUv‡Z, cwi‡lev †c‡Z Ges cwievi I Ab¨vb¨ mvgvwRK mnvqZvi mv‡_ mshy³ n‡Z mvnvh¨ Kiæb|  (AviI) ¶wZ †_‡K e¨w³‡K i¶v Kiæb| » gvbwmK Pvc Kgv‡bv I mvgvwRK mnvqZv evov‡bvi bxwZgvjvi (>> †mevi mvaviY g~jbxwZ) eY©bv Abyhvqx AwZwi³ g‡bvmvgvwRK mnvqZv cÖ`vb Kiæb: ◆ eZ©gvb g‡bvmvgvwRK Pv‡ci Drm¸‡jv‡K wPwýZ Kiæb| ◆ mvgvwRK mnvqZv kw³kvjx Kiæb| ◆ Pvc †gvKv‡ejvi †KŠkj †kLvb| » wMÖd/KvD‡K nviv‡bvi Ges Zxeª gvbwmK Pv‡c ¯^vfvweK cÖwZwµqv m¤ú‡K© e¨w³‡K †kLvb, D`vniY: ◆ GB ai‡bi NUbvi ci gvby‡li GB cÖwZwµqv¸‡jv †`Lv hvq| ◆ †ewkifvM †ÿ‡Î, cÖwZwµqvmg~n mg‡qi mv‡_ mv‡_ K‡g hvq| » mgmvgwqK Ae¯’vi e¨e¯’vcbv Kiæb| 2. Zxeª gvbwmK Pv‡ci jÿY wn‡m‡e Ny‡gi mgm¨v n‡j wb¤œwjwLZ AwZwi³ e¨e¯’vcbv w`b: » e¨vL¨v Kiæb †h, AwZwi³ gvbwme Pv‡ci ci mvaviYZ gvby‡li g‡a¨ Ny‡gi mgm¨v (Awb`ªv/Bb‡mvgwbqv) ˆZwi nq| » Bb‡mvgwbqv/Awb`ªvi †Kvb cvwicvwk¦©K KviY Av‡Q wK-bv, Zv wPwýZ I we‡kølY Kiæb| » Bb‡mvgwbqv/Awb`ªvi †Kvb kvixwiK KviY Av‡Q wK-bv, Zv wPwýZ I we‡kølY Kiæb (†hgb, kvixwiK e¨v_v)| » wbqvwgZ Ny‡gi iæwUbmn w¯øc nvBwRb m¤ú‡K© civgk© w`b (†hgb, Nygv‡Z hvIqv I Nyg †_‡K IVvi wbqwgZ mgq) , Kwd, wb‡KvwUb Ges w`‡bi †kl mg‡q ev Nygv‡Z hvIqvi Av‡M A¨vj‡Kvnj ev g` cvb Gwo‡q Pjv| †Rvi w`‡q ejyb, A¨vj‡Kvnj Ny‡gi e¨vN¨vZ NUvq| » e¨wZµgxfv‡e, AZ¨šÍ ¸iæZi †ÿ‡Î †hLv‡b g‡bv‰eÁvwbK wPwKrmv (†hgb, wkw_jvqb †KŠkjmg~n) m¤¢e bq A_ev Kvh©Kix bq, Ges Awb`ªv ˆ`wbK KvR K‡g© h‡_ó Amyweav m„wó K‡i, †m‡¶‡Î ¯^í‡gqv‡` (3-7 w`b) benzodiazepines Gi wPwKrmv we‡ePbv Kiv †h‡Z cv‡i| ◆ gvÎv: ▸ cÖvß eq¯‹‡`i Rb¨, Nygv‡Z hvIqvi mgq 2-5 wg.MÖv. WvqvwRcvg w`b| ▸ eq¯‹‡`i †ÿ‡Î Nygv‡Z hvIqvi mgq 1-2.5 wg.MÖv. WvqvwRcvg w`b| ▸ WvqvwRcvg †`Iqvi Av‡M Ab¨ Ily‡ai mv‡_ m¤úK© hvPvB K‡i wbb| ▸ Z›`ªv”QbœZv I †ckx y`e©jZvmn †eb‡RvwWqvwRwcb‡mi mvaviY wKQz cvk¦©cÖwZwµqv i‡q‡Q| ▸ mveavbZv: †eb‡RvwWqvwRwcbm wbf©iZv ˆZwi Ki‡Z cv‡i| ZvB GwU †Kej ¯^í †gqv`x wPwKrmvq e¨envi Kiæb| ◆ `ªóe¨: ▸ GB wPwKrmv †Kej cÖvß eq¯‹‡`i Rb¨| ▸ wkï I wK‡kvi-wK‡kvix‡`i †eb‡RvwWqvwRwcbm w`‡eb bv| ▸ Mf©eZx ev cÖmywZ gv‡q‡`i GB Ilya †`qv †_‡K weiZ _vKzb| ▸ eq¯‹ e¨w³‡`i †ÿ‡Î GB Ilya w`‡j evievi cvk¦©cÖwZwµqvi w`‡K bRi ivLyb| ▸ P~ovšÍ ¸iæZi Ny‡gi mgm¨vi †ÿ‡Î GUv mvgwqK mgvavb| ▸ †eb‡RvwWqvwRwcbm Kv‡iv g„Zz¨ RwbZ †kv‡Ki Kvi‡Y m„ó Awb`ªvq cÖvßeq¯‹ I wkï‡`i †ÿ‡Î e¨envi Kiv DwPZ bq| ▸ †eb‡RvwWqvwRwcbm Zxeª gvbwmK Pvc ev wcwUGmwWi Ab¨ †Kvb jÿ‡Yi †ÿ‡Î e¨envi Kiv DwPZ bq| 3 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event >> WHO, WTF & WVI, 2013). A C U 21 3. Zxeª gvbwmK Pv‡ci jÿY wn‡m‡e wkï‡`i †eWI‡qwUs n‡j wb¤œwjwLZ AwZwi³ e¨e¯’vcbv w`b: » GKwU gvbwmK Pvcc~Y© NUbvi ci †_‡K †eWI‡qwUs ïiæ n‡q‡Q wK-bv, Zv wbwðZ n‡Z Gi BwZnvm Rvbyb| Ab¨vb¨ m¤¢ve¨ KviY (†hgb, g~Îbvjxi msµgY) †ei Kiæb Ges e¨e¯’vcbv wbb| » e¨vL¨v Kiæb: ◆ gvbwmK Pv‡ci ci wkï‡`i g‡a¨ †eWI‡qwUs GKwU mvaviY, wb‡ ©`vl cÖwZwµqv| ◆ †eWI‡qwUs‡qi Rb¨ wkï‡`i kvw¯Í †`Iqv DwPZ bq, KviY G‡Z wkï g‡a¨ gvbwmK Pvc Av‡iv evo‡e Ges mgm¨v Lviv‡ci w`‡K †h‡Z cv‡i| mevi mvg‡b wkï‡K †eWI‡qwUs‡qi K_v e‡j Zv‡K weeªZ Kiv hZœKvixi DwPZ bq| ◆ hZœKvixi kvšÍ _vK‡Z n‡e Ges Av‡eMxqfv‡e mnvqK n‡Z n‡e| » mvgvb¨ AvPiYMZ wPwKrmvi Ici hZœKvix‡K cÖwkÿY †`qvi welqwU we‡ePbvq wb‡Z cv‡ib ( †hgb, Ny‡gi Av‡M AwZwi³ Zij Lvevi Gwo‡q Pj‡j cyi¯‹…Z Kiv, Ny‡gi Av‡M cÖmªve Kiv‡K cyi¯‹…Z Kiv, iv‡Z ïK‡bv Lvevi †L‡j cyi¯‹…Z Kiv)| wkïiv cQ›` K‡i Ggb †h †Kvb wKQzB cyi¯‹vi n‡Z cv‡i, †hgb- AwZwi³ †Ljvi mgq, GKwU †jLwP‡Îi ZviKv ev mgZzj¨ wKQz| 4. Zxeª gvbwmK Pv‡ci jÿY wn‡m‡e nvBcvi‡fw›U‡jkb (AwZwi³ `ªæZ k¦vm-cÖk¦vm, Awbqwš¿Z) n‡j wb¤œwjwLZ AwZwi³ e¨e¯’vcbv w`b: » Ab¨vb¨ me KviY ev` w`b I e¨e¯’vcbv wbb, GgbwK nvBcvi‡fw›U‡jkb GKwU gvbwmK Pvcc~Y© NUbvi wVK ciciB ïiæ n‡jI| me mgq dzmdz‡mi †iv‡Mi g‡Zv kvixwiK KviY †ei Ki‡Z cÖ‡qvRbxq †gwW‡Kj cixÿv Kiv‡eb| » hw` †KvbI kvixwiK KviY mbv³ bv nq, Zvn‡j Ggb e¨w³wU‡K Avk¦vm †`Iqv DwPZ †h nvBcvi‡fw›U‡jkb KLbI KLbI Zxeª gvbwmK Pv‡ci Kvi‡Y nq Ges GwU wPwKrmv Kivi g‡Zv eo †Kvb mgm¨v bq| » kvšÍ _vKzb Ges m¤¢e n‡j D‡Ø‡Mi m¤¢ve¨ KviY AcmviY Kiæb| e¨w³‡K ax‡i ax‡i k¦vm-cÖk¦vm PP©vi gva¨‡g ¯^vfvweK n‡Z mvnvh¨ Kiæb| (>>†mevi mvaviY g~jbxwZ‡Z gvbwmK Pvc Kgv‡bv I mvgvwRK mnvqZv kw³kvjxKiY bxwZgvjv) (KvM‡Ri e¨v‡M k¦vm †bIqvi civgk© †`‡eb bv)| 5. Zxeª gvbwmK Pv‡ci DcmM© wnmv‡e kix‡ii mv‡_ m¤úwK©Z wew”Qbœ DcmM© (†hgb, ¯v^¯’¨ cix¶vq bv cvIqv c¨vivjvBwmm, K_v ej‡Z ev †`L‡Z bv cviv, ÒwmD‡WvwmRviÓ) n‡j wb‡Pi AwZwi³ e¨e¯’vcbv w`b: » Ab¨ m¤¢ve¨ KviY¸‡jv ev` w`b I e¨e¯’vcbv Kiæb, GgbwK j¶Y¸‡jv gvbwmK Pvcc~Y© NUbvi wVK cici ïiæ n‡jI| me mgq m¤¢ve¨ kvixwiK KviY wPwýZ Ki‡Z cÖ‡qvRbxq cix¶v Kivb| wmRvim&/Kbfvjkbm m¤úK©xq †gwW‡Kj cix¶vi Ici bxwZgvjvi Rb¨ g„Mx gwWDj †`Lyb (>> EPI). » e¨w³i †fvMvwšÍ ¯^xKvi Kiæb Ges kª×vc~Y© g‡bvfve eRvq ivLyb| †h‡Kvb cÖvw߇K †Rvi †`qv Gwo‡q Pjyb, hv‡Z e¨w³ DcmM© †_‡K †c‡Z cv‡i| » j¶Y¸wj m¤c‡K© e¨w³i wbR¯^ e¨vL¨vwU Rvb‡Z Pvb Ges ¯^v¯’¨ cix¶v bv cvIqv †mvgvwUK j¶‡Yi Ici mvaviY wb‡ ©`kbv cÖ‡qvM Kiæb (>> OTH)| » e¨w³‡K cybivq Avk¦¯Í Kiæb †h, fxlY gvbwmK Pvc Abyfe‡bi ci GB DcmM©¸wj KLbI KLbI ˆZwi nq Ges m¤¢eZ GUv ¸iæZi †gwW‡Kj mgm¨v bv| » ¶wZ †bB Ggb wbw`©ó mvs¯‹…wZK wPwKrmvi e¨envi we‡ePbv Kiæb| 6. e¨w³wU‡K 2-4 mßv‡ni g‡a¨ Avevi Avm‡Z ejyb, hw` Dcm‡M©i DbœwZ bv nq, A_ev †h †Kvb mgq hw` DcmM©¸wj AviI Lviv‡ci w`‡K hvq| 23 GRI Zxeª †kvK gvbweK wech©‡qi g‡a¨cÖvßeq¯‹‡`i, wK‡kvi-wK‡kvix Ges wkï‡`i cÖvqB eo ¶wZi m¤§yLxb nq| Zxeª †kvK n‡jv GKwU ÿwZi ci Av‡eMxq †fvMvwšÍ| hw`I ¶wZi †ewkifvM cÖwZwµqv gvbwmK e¨vwa bv n‡q AvZ¥-wbqwš¿Z _v‡K, Zxeª †kv‡Ki ¸iæZ¡c~Y© DcmM© wb‡q mvnv‡h¨i Rb¨ gvbyl ¯^v¯’¨ †K›`ª¸‡jv‡Z nvwRi nq| GKwU ¶wZi ci, wPwKrm‡`i wb‡Pi welq¸wj wPwýZ Kiv cÖ‡qvRb: » Zxeª †kv‡Ki D‡jøL‡hvM¨ j¶Y (wRAviAvB) Zxeª gvbwmK Pv‡ci DcmM©¸wji gZ hviv †kvKvnZ, Zviv Awbw`©ó gvbwmK I ¯^v¯’¨ cixÿvq bv cvIqv AmsL¨ kvixwiK Awf‡hvM Avb‡Z cv‡ib| wKQz nviv‡bvi ci gvby‡li g‡a¨ Zxeª †kv‡Ki D‡jøL‡hvM¨ †`Lv †`q, hw` wK-bv GB me DcmM© Zv‡`i ˆ`bw›`b Kv‡R (mvs¯‹…wZKfv‡e cÖZ¨vkvi evB‡i) h‡_ó Amyweavi m„wó K‡i, A_ev hw` Dcm‡M©i Rb¨ gvbyl mvnvh¨ Pvq| eZ©gvb gwWD‡j Zxeª †kv‡Ki D‡jøL‡hvM¨ j¶Y A¨v‡mm‡g›U I cwiPh©v/e¨e¯’vcbv †`Lv n‡q‡Q| » `xN©vwqZ †kv‡Ki e¨vwa hLb Zxeª †kv‡Ki D‡jøL‡hvM¨ j¶Y¸wj AwZwi³ mgq Ae¨vnZ _v‡K, ZLb gvby‡li g‡a¨ `xN©wqZ †kvK e¨vwa ˆZwi nq| GB Ae ’¯vq ¸iæZi wPšÍv-AvweóZv A_ev g„Z e¨w³i Rb¨ ¸iæZi †e`bvmn Mfxi AvKv•ÿv Ges ˆ`bw›`b Kv‡R Kgc‡¶ 6 gvm (Ges e¨w³i cÖZ¨vwkZ ms¯‹…wZi Zzjbvq †kv‡Ki †gqv` Zvi †P‡qI †ewk n‡Z cv‡i) mgm¨v ˆZwi nq| Gme †¶‡Î, ¯^v ’¯¨‡mev cÖ`vbKvix‡`i GKRb we‡kl‡Ái civgk© †bqv cÖ‡qvRb| » mgm¨v I e¨vwamg~n Zxeª gvbwmK Pvc †`Lv †`qvi ci n‡Z cv‡i (†hgb, g„Zz¨i Kvi‡Y †kvK), wKš‘ †m¸‡jvi Abycw ’¯wZ‡ZI Zv n‡Z cv‡i| G¸‡jvi g‡a¨ i‡q‡Q: gvSvwi-¸iæZi welYœZv †ivM (>> DEP), mvB‡Kvwmm (>> PSY), A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi (>> SUB), AvZ¥nZ¨v (>> SUI) Ges Ab¨vb¨ ¸iæZ¡c~Y© gvbwmK ¯^v ’¯¨ cxov (>> OTH) » †hme cÖwZwµqv wPwKrmv e¨e¯’vq ¸iæZ¡c~Y© bq Ges hvi Rb¨ wK¬wbK¨vj e¨e¯’vcbvi cÖ‡qvRb nq bv| me cÖwZwµqvi g‡a¨ G¸‡jv LyeB mvaviY| G¸‡jvi g‡a¨ ÿY ’¯vqx cÖwZwµqv i‡q‡Q, hvi Rb¨ gvbyl mvnvh¨ †Lvu‡R bv Ges †h¸wj mvs¯‹…wZKfv‡e †g‡b †bqvq Zv‡Z ˆ`bw›`K KvR e¨vnZ nq bv| G me †¶‡Î, ¯^v ’¯¨ cÖ` vbKvix‡`i mnvqK n‡Z n‡e, e¨w³i cÖ‡qvRb I D‡ØM‡K eyS‡Z n‡e Ges ch©‡eÿY Ki‡Z n‡e cÖvK…wZKfv‡e my¯’ n‡”Q wKbv; hv‡nvK, GB ai‡bi cÖwZwµqvq wPwKrmv e¨e ’¯vcbvi cÖ‡qvRb †bB| G R I A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1: e¨w³ wK m¤cÖwZ GKwU eo ¶wZi wkKvi n‡q‡Qb? » wRÁvmv Kiæb e¨w³wU eo ¶wZi m¤§yLxb n‡q‡Q wK-bv| wRÁvmv Ki‡Z cv‡ib:  wKfv‡e `y‡h©vM / msNvZ Avcbv‡K ÿwZMÖ¯Í K‡i‡Q?  Avcwb wK cwievi ev eÜy‡`i nvwi‡q‡Qb? Avcbvi Ni?  Avcbvi PvKwi ev RxweKv? Avcbvi m¤cÖ`vq?  wKfv‡e GB ¶wZ Avcbvi cÖfvweZ K‡i‡Q?  cwiev‡ii †KvbI m`m¨ ev eÜy nvwi‡q‡Q wK? » wRÁmv Kiæb, NUbv NUvi ci KZmgq †cwi‡q †M‡Q? » hw` MZ 6 gv‡mi g‡a¨ eo †Kvb ¶wZ n‡q _v‡K, Z‡e A¨v‡mm‡g›U cÖkœ 2 G hvb| » hw` MZ 6 gv‡miI †ewk mgq Av‡M eo †Kvb ¶wZ n‡q _v‡K, A_ev hw` m¤¢ve¨ UªgvwUK NUbvq GK gv‡miI †ewk mgq Av‡M N‡U, Z‡e GB bxwZgvjv Abyhvqx Ab¨vb¨ Ae¯’v (>> DEP, PTSD, PSY, SUB) we‡ePbvq Avbyb A_ev `xN©vwqZ Zxeª †kv‡Ki †ivM| A¨v‡mm‡g›U cÖkœ 2: hw` MZ 6 gv‡mi g‡a¨ GKwU eo ¶wZ N‡U _v‡K, Z‡e wK IB e¨w³i g‡a¨ Zxeª †kv‡Ki ¸iæZ¡c~Y© DcmM© i‡q‡Q? » hvPvB Kiæb:  welYœZv, D‡ØM, ivM, nZvkv  ¶wZi m‡½ AvKv•¶v  AbvûZ ¯§„wZ *, g„Z y¨i Qwe I wPšÍv  ¶zav nªvm cvIqv  kw³ nªvm  Ny‡gi mgm¨v  g‡bv‡hv‡M mgm¨v  mgvR wew”QbœZv I cÖZ¨vnvi  wPwKrmv weÁv‡b e¨vL¨vnxb (†gwW‡Kj cixÿvq bv cvIqv) kvixwiK mgm¨v (†hgb, eyK aodovwb, gv_ve¨v_v, mvaviY e¨v_¨v mvs¯‹…wZKfv‡e we‡kl †kvK cÖwZwµqv (†hgb- g„Z e¨w³i Kɯ^i †kvbv, ¯^‡cœ g„Z e¨w³i mv‡_ †`Lv Kiv)| » Zxeª †kv‡Ki D‡jøL‡hvM¨ j¶Y _vK‡Z cv‡i, hw` bv wb‡Pi me¸‡jv µvB‡Uwiqvi mv‡_ wg‡j hvq:  cÖvq 6 gv‡mi g‡a¨ GK ev GKvwaK ¶wZ  Dc‡ii †h †Kvb DcmM© ¶wZi ci ïiæ nq  Dcm‡M©i Kvi‡Y (mvs¯‹…wZKfv‡e cÖZ¨vwk‡Zi †P‡q †ewk n‡j) gvbyl mvnvh¨ Pvq A¨v‡mm‡g›U cÖkœ 3: †mLv‡b †Kvb mgmvgwqK Ae¯’v Avi Av‡Q wK? » kvixwiK Ae¯’v hvPvB Kiæb hv‡Z DcmM©¸‡jv e¨vL¨v cvIqv hvh, Ges cvIqv †M‡j †mfv‡eB e¨e¯’vcbv cÎ w`b| » GB wb‡ ©`wkKvq D‡jøwLZ Ab¨ †Kvb gvbwmK, ¯œvqyweK I gv`K`ªe¨ e¨envi (GgGbGm) Ae¯’v (welYœZvmn), hvi DcmM©mg~n e¨vL¨v Kiv hvq Ges †mB Abyhvqx e¨e¯’vcbv Kiæb, hw` cvIqv hvq| 4 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. 25 †gŠwjK e¨e¯’vcbv cwiKíbv 1. g~j wPwKrmv cwiKíbv5 » g‡bv‡hvM mnKv‡i ïbyb, K_v ejvi Rb¨ e¨w³wU‡K Pvc †`‡eb bv| » e¨w³‡K Zvi †gŠwjK Pvwn`v I D‡Ø‡Mi welq¸‡jv m¤c‡K© wRÁvmv Kiæb| » †gŠwjK Pvwn`v c~iY, cwi‡lev †c‡Z Ges cwievi I Ab¨vb¨ mvgvwRK mnvqZvq e¨w³‡K hy³ n‡Z mvnvh¨ Kiæb| » AviI ¶wZ †_‡K e¨w³‡K i¶v Kiæb 2. gvbwmK Pvc Kgv‡bv Ges mvgvwRK mn‡hvwMZv kw³kvjxKiY wb‡ ©`wkKvq †hfv‡e ewY©Z, †mfv‡e AwZwi³ g‡bvmvgvwRK mnvqZv w`b (>> †mevi mvaviY g~jbxwZ) » eZ©gvb g‡bvmvgvwRi Pv‡ci KviY wPwýZ Kiæb| » mvgvwRK mnvqZv e„w× Kiæb » gvbwmK Pvc e¨e¯’vcbv †kLvb| 3. ¶wZi mvaviY cÖwZwµqv m¤c‡K© e¨w³‡K AeMZ Kiæb, †hgb: » eo ¶wZi ci gvbyl wewfbœfv‡e cÖwZwµqv e¨³ Ki‡Z cv‡i| wKQz gvbyl „`p Av‡eM †`Lvq, Ab¨iv Zv Avevi K‡i bv| » Kvbœv KL‡bvB wb‡ ©`k K‡i bv †h Avcwb y`e©j| » hviv KvbœvKvwU K‡i bv Zviv Mfxifv‡e gvbwmK e¨v_v Abyfe K‡i, wKš‘ GUv cÖKv‡ki Ab¨ Dcvq Av‡Q| » Avcwb g‡b Ki‡Z cv‡ib †h, y`tL I †e`bv hv Avcwb Abyfe K‡ib, Zv KL‡bvB hv‡e bv, Z‡e †ekxifvM †¶‡Î, GB Abyf‚wZ¸wj mg‡qi mv‡_ mv‡_ K‡g hvq| » KLbI KLbI †Kvb e¨w³ wKQzw`‡bi Rb¨ fv‡jv Abyfe Ki‡Z cv‡ib, Zvici wKQz wRwbm Zv‡`i ¶wZi K_v ¯§iY Kwi‡q †`q Ges Zviv cÖ_gev‡ii g‡ZvB Lvivc Abyfe K‡i| GUvB ¯^vfvweK Ges Avevi GB AwfÁZvi ZxeªZv I evievi wd‡i Avmv mg‡qi mv‡_ mv‡_ K‡g hvq| » `ytL Abyf‡ei †KvbI mwVK ev fzj Dcvq †bB| KLbI KLbI Avcwb Lye y`twLZ n‡Z cv‡ib, Ges Ab¨ mg‡q Avcwb wb‡RB Avb›` Dc‡fvM Ki‡Z cv‡ib| GB gyû‡Z© Avcbvi Abyf‚wZi Rb¨ wb‡Ri mgv‡jvPbv Ki‡eb bv| 4. mgmvgwqK Ae ’¯vi e¨e¯’vcbv| 5. h_vh_ mvs¯‹…wZK mgš^q / †kvK cÖKv‡ki * cÖwµqv wb‡q Av‡jvPbv I mg_©b » h_vh_ †kvK Abyôvb / ixwZ Av‡Q wK-bv wRÁvmv Kiæb A_ev cwiKíbv n‡q‡Q wK-bv| hw` bv _v‡K, †kvK cvj‡bi evav I Kgv‡bvi Dcvq¸‡jv wb‡q Av‡jvPbv Kiæb| » gi‡`‡ni wK n‡qwQj, Rvbyb| hw` gi‡`n bv cvIqv hvq, Z‡e Zv‡K Zv Lyu‡R †c‡Z mvnvh¨ Kiæb| » gi‡`n cvIqv bv †M‡j ¯§„wZ msiÿ‡Yi weKí Dcvq wb‡q Av‡jvPbv Kiæb, †hgb- ¯§„wZ¯§viK| 6. hw` wek¦vm‡hvM¨ Ges mvs¯‹…wZKfv‡e h_vh_ nq, Z‡e Av‡Mi g‡Zv ¯^vfvweK Kvh©µg¸‡jv‡Z (†hgb, ¯‹zj ev Kg©‡¶Î, evwoi KvR ev mvgvwRK KvR) wdi‡Z Drmvn w`b| 7. mv¤cÖwZK ¶wZ cieZ©x Ny‡gi mgm¨v, †eWI‡qwUs, nvBcvi‡fw›U‡jkb Ges wW‡mvwm‡qwUf DcmM©¸‡jvi we‡kl e¨e¯’vcbvi Rb¨ Zxeª gvbwmK Pv‡ci gwWD‡ji mswkøó wefvM¸wj †`Lyb (>>ACU) 5 The approach described here is often referred to as psychological first aid (PFA) when applied in the immediate aftermath of an extremely stressful event (>> WHO, WTF & WVI, 2013). Zxeª †kv‡Ki DcmM©mg~‡ni wPwKrmv/e¨e ’¯vcbvq Ilya w`‡eb bv (hw` bv we‡kl cÖ‡qvRb nq) 8. e¨w³ hw` Aí eqmx wkï nq: » wkïi weKvk gvÎv Abyhvqx Zvi cÖ‡kœi cwi¯‹vi I mZZvi mv‡_ Reve w`b| †Kvb ¶wZ m¤ú‡K© wRÁvmv Ki‡j wg_¨v ej‡eb bv (Avgvi gv †Kv_vq?)| GUv wØav ˆZwi Ki‡Z cv‡i Ges †mev cÖ`vbKvixi cÖwZ e¨w³i wek¦vm bó n‡Z cv‡i| » Aíeq¯‹ ev”Pv‡`i g‡a¨ mvaviYfv‡e _vKv Ôhv y`Kix wPšÍvÕ hvPvB Kiæb I ms‡kvab K‡i w`b (†hgb, wkïiv g‡b Ki‡Z cv‡i †h, ¶wZi Rb¨ ZvivB `vwq; D`vniY¯^iƒc, Zviv g‡b Ki‡Z cv‡i †h, Zv‡`i AvcbRb gviv †M‡Q, KviY Zviv `yó wQ‡jv A_ev Zviv Zv‡`i cÖwZ Amš‘ó wQ‡jb)| 9. wkï, wK‡kvi-wK‡kvix Ges Ab¨ hviv ¶wZi wkKvi, hviv wcZvgvZv ev AvcbRb nvwi‡q‡Qb, Zv‡`i wbivcËvi cÖ‡qvRb †gUvb Ges wbiew”Qbœ I mnvqZvc~Y© hZœ wbb, g‡bvmvgvwRK mnvqZvmn| » cÖ‡qvRb n‡j e¨w³‡K wek¦¯ Í wbivcËv cÖ`vbKvix ms¯’v/ †bUIqv‡K©i mv‡_ †hvMv‡hvM Kwi‡q w`b 10. hw` `xN©vwqZ Zxeª †kv‡Ki †ivM m‡›`n nq, cieZ©x g~j¨vqb I e¨e¯’vcbvi Rb¨ GKRb we‡kl‡Ái mv‡_ Av‡jvPbv Kiæb| » e¨w³i g‡a¨ `xN©vwqZ Zxeª †kvKRwbZ †ivM †`Lv w`‡Z cv‡i, hw` g„Zz¨RwbZ †kv‡Ki g‡a¨ AšÍZ Qq gvm a‡i g„Z e¨w³‡K wb‡q AvweóZv, A_ev g„Z e¨w³i cÖwZ Zxeª AvKv¼vi mv‡_ `xN©vwqZ Av‡eMxq †e`bv Ges ˆ`bw›`b KvRKg© cvj‡b h‡_ó weNœZv †`Lv †`q| 11. hw` j¶Ymg~‡ni DbœwZ bv nq, Z‡e 2-4 mßv‡ni g‡a¨ A_ev hw` j¶Ymg~‡ni Av‡iv AebwZ nq, Z‡e †h †Kvb mgq Avev‡iv Avm‡Z ejyb| 17 6 This period may be longer than 6 months in cultures where the expected duration for mourning/bereavement is longer than 6 months. 27 gvSvwi-¸iæZi welYœZvRwbZ †ivM cÖvßeq¯‹, wK‡kvi-wK‡kvix Ges ev”Pv‡`i g‡a¨ gvSvwi-¸iæZi welYœZvRwbZ †ivM †`Lv w`‡Z cv‡i, hviv †Kv‡bv wbw`ó gvbwmK Pv‡ci m¤§yLxb nqwb| KwgDwbwUi g‡a¨B wKQz gvbyl cvIqv hv‡e, hviv gvSvwi-¸iæZi welYœZvRwbZ †iv‡M fyM‡Qb| hv‡nvK, Riæwi gvbweK cwiw ’¯wZ‡Z eo ai‡bi ¶wZ I gvbwmK Pv‡c AvµvšÍ n‡j Zxeª †kvK, fq, Aciva‡eva, j¾v I nZvkvi Rb¥ w`‡Z cv‡i, hv gvSvwi-¸iæZi welYœZvRwbZ †iv‡Mi SzuwK evovq| Z‡e, Gme Av‡eM AwZmv¤úªwZK cÖwZK‚j cwi‡e‡ki ¯^vfvweK cÖwZwµqvI n‡Z cv‡i| gvSvwi-¸iæZi welYœZvRwbZ †iv‡Mi wPwKrmvi K_v ZLbB we‡ePbv Ki‡Z n‡e, hw` GB j¶Ymg~n Uvbv K‡qK mßvn a‡i _v‡K Ges cwiYv‡g ˆ`bw›`b KvR Pvwj‡q †h‡Z h‡_ó mgm¨vi m¤§yLxb nb| gvSvwi-¸iæZi welYœZvRwbZ †iv‡Mi ˆewkó¨/jÿYmg~nt  kw³ Kg, Aemv`, Ny‡gi mgm¨v  wbw`©ó KviY QvovB †ek K‡qKwU `xN©‡gqv`x kvixwiK j¶Y (e¨v_v I †e`bv)  Uvbv wbivb›` ev welYœ gb, D‡ØM  KvRK‡g© AvMÖn ev Avb›` K‡g hvIqv DEP 29 A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1: e¨w³i wK gvSvwi-¸iæZi welYèZvRwbZ †ivM Av‡Q? » wbgœwjwLZ welq¸‡jv wea©viY Kiæb:7 K. e¨w³i gv‡S wb‡Pi welYœZvRwbZ †iv‡Mi cÖavb j¶Y¸‡jvi g‡a¨ AšÍZ GKwU Kgc‡¶ 2 mßvn a‡i i‡q‡Q:  Uvbv welYè gb ▸ wkï I wK‡kvi-wK‡kvix‡`i Rb¨: wLUwL‡U fve ev welYè gb  Kg©Kv‡Ð D‡jøL‡hvM¨ cwigv‡Y AvMÖn ev Avb›` K‡g hvIqv, GgbwK †mme Kv‡R Avb›` †c‡Zv ▸ cieZ©x‡Z †hŠb AvMÖnI K‡g hvq| L. wb‡Pi welYœZvRwbZ †iv‡Mi j¶Ymg~‡ni g‡a¨ AšÍZ GKvwaK jÿY e¨w³i g‡a¨ wbw`©ó gvÎvq (A_ev wb‡Pi Ab¨vb¨ j¶Ymg~‡ni A‡bK¸‡jv Kg gvÎvq) Kgc‡¶ 2 mßvn i‡q‡Q:  Ny‡gi mgm¨v A_ev AwZwi³ Nyg  D‡jøL‡hvM¨ gvÎvq Lvev‡ii iæwP ev IR‡bi cwieZ©b (†e‡o hvIqv ev K‡g hvIqv)  wb‡R‡K g~j¨nxb g‡b Kiv ev AwZwi³ Aciva‡eva  K¬všÍ jvMv ev kw³ K‡g hvIqv  g‡bv‡hvM K‡g hvIqv ev †Kvb Kv‡R †ewk¶Y g‡bv‡hvM a‡i ivL‡Z bv cviv  wm×všÍnxbZv  `„k¨gvb Aw¯’iZv ev kvixwiK Aw¯’iZv  mvavi‡Yi †P‡q A‡bK wa‡i wa‡i K_v ejv ev Pjv‡div Kiv  fwel¨r wb‡q nZvkv  AvZ¥nZ¨vi wPšÍv ev †Póv M. e¨w³MZ, cvwievwiK, mvgvwRK, wk¶vMZ, Kg©‡ÿÎ/‡ckvMZ Ab¨vb¨ ¸iæZ¡c~Y© †¶‡Î ˆ`bw›`b Kvh©Kjv‡c D‡jL‡hvM¨ gvÎvq weNœ NUvq| » hw` K, L Ges M Gi me¸‡jv j¶Y Kgc‡¶ 2 mßvn a‡i _v‡K, Z‡e gvSvwi-¸iæZi welYœZvRwbZ †ivM Av‡Q e‡j aiv hvq|  wWwjDkb* ev n¨vjywm‡bkb* _vK‡Z cv‡i| †mRb¨ cix¶v Kiæb| hw` †_‡K _v‡K, Z‡e welYœZvRwbZ †iv‡Mi wPwKrmvq cwiea©b cÖ‡qvRb| G‡ÿ‡Î GKRb we‡kl‡Ái civgk© wbb| » hw` e¨w³i j¶Ymg~n gvSvwi-¸iæZi welYœZvRwbZ mgm¨vi mv‡_ bv †g‡j, Z‡e eZ©gvb jÿYmg~‡ni g~j¨vqb I wPwKrmvi Rb¨ >> OTH gwWD‡j hvb| A¨v‡mm‡g›U cÖkœ 2: j¶Ymg~‡ni wK Ab¨ †Kvb e¨vL¨v Av‡Q (gvSvwi-¸iæZi welYœZvRwbZ †ivM e¨ZxZ)? » welYèZv RwbZ gvbwmK †iv‡Mi Abyiƒc GKB mv‡_ msNwUZ kvixwiK Ae¯’v¸‡jv ev` w`b|  i³¯^íZv, Acywó, nvB‡cv_vBi‡qwWRg, †÷ªvK Ges Ily‡ai e¨envi RwbZ cvk¦© cÖwZwµqv ev` w`b Ges wPwKrmv wbb (D`vniY¯^iƒc- †÷i‡qW Gi e¨envi RwbZ g‡bi cwieZ©b*) » g¨vwbK Gwc‡mv‡Wi BwZnvm ev` w`b  g~j¨vqb Kiæb †h, AZx‡Z Ggb †Kvb `xN© mgq AwZevwnZ n‡q‡Q wKbv, hLb wb‡¤œv³ j¶Y¸‡jv GKB mg‡q †`Lv wM‡qwQ‡jv ▸ Ny‡gi cÖ‡qvRb K‡g hvIqv ▸ Drdzjø, D”Q¡wmZ A_ev wLUwL‡U fve ▸ wPšÍv¸wj gv_vi g‡a¨ †`Šov‡”Q; mn‡RB Pvicv‡ki AcÖ‡qvRbxq e¨vcvi Øviv wewÿß nIqv ▸ Kg©ZrciZv †e‡o hvIqv, kw³ †e‡o †M‡Q e‡j g‡b nIqv ev `ªæZ K_v ejv ▸ Av‡eMZvwoZ ev †ec‡ivqv AvPiY, †hgb- AwZwi³ Ryqv †Ljv I LiP Kiv, cwiKíbv QvovB ¸iæZ¡c~Y© wm×všÍ †bqv ▸ wb‡Ri m¤c‡K© Aev¯Íe D”P aviYv †cvlY Kiv  A¨v‡mm Kiæb, j¶Ymg~n ˆ`bw›`b KvR‡K KZUzKz evavMÖ¯’ Ki‡Q, ev wb‡Ri A_ev A‡b¨i Rb¨ KZUv wec`RbK| D`vniY¯^iƒc: ▸ Avcbvi AwZwi³ Kvh©Kjvc Avcbvi ev Avcbvi cwiev‡ii Rb¨ wK mgm¨v ˆZwi K‡iwQj? Avcbvi GB AvPi‡Yi Rb¨ †KD wK Avcbv‡K nvmcvZv‡j fwZ© Kiv‡bv ev evmvq AvU‡K ivLvi †Póv K‡i‡Qb?  hw` wb‡Pi y`ÕwU welqB †_‡K _v‡K, Z‡e g¨vwbK Gwc‡mv‡Wi BwZnvm Av‡Q ejv hvqt ▸ hw` Dc‡ii 6wU j¶‡Yi †ewkifvMB 1 mßv‡ni †ewk mgq wQj ▸ j¶Ymg~n ˆ`bw›`b KvRK‡g© D‡jøL‡hvM¨ mgm¨v ˆZwi K‡iwQj A_ev Zv wb‡Ri ev A‡b¨i Rb¨ ûgwK wQj/wec` nq  hw` KLbI †Kvb g¨vwbK Gwc‡mvW †`Lv w`‡q _v‡K, Zvn‡j welYœZv evB‡cvjvi wWmAW©vi* bv‡gi Av‡iKwU †iv‡Mi Ask wn‡m‡e _vK‡Z cv‡i Ges wfbœ wPwKrmvi cÖ‡qvRb (gwWD‡ji †k‡l >> Box DEP 2)| » eo ai‡bi ¶wZ‡Z mvaviY cÖwZwµqv¸‡jv ev` w`b (†hgb, g„Zz¨RwbZ †kvK, ¯’vbvšÍi >> GRI)|  eo ai‡bi ¶wZi cÖwZwµqv‡K ZLbB ¯^vfvweK ej‡ev, hw`: ▸ wPwKrmv Qvov mg‡qi mv‡_ mv‡_ D‡jøL‡hvM¨ DbœwZ nIqv ▸ wb‡Ri †Kvb DcmM©B eZ©gvb †bB g~j¨nxb e‡j wek¦vm Kiv  AvZ¥nZ¨vi wPšÍv  ¯^vfvwe‡Ki †P‡q †ewk ax‡i K_v ejv ev PjvPj Kiv  mvB‡KvwUK j¶Y (wWwjDkb ev n¨vjywm‡bkb) ▸ welYœZv ev g¨vwbK Gwc‡mv‡Wi AZxZ BwZnvm †bB Ges ▸ j¶Ymg~n e¨w³i ˆ`bw›`b KvRK‡g© D‡jøL‡hvM¨ mgm¨v ˆZwi K‡i bv|  e¨wZµgt wbKU AvZ¥x‡qi g„Zy¨i ci ˆ`bw›`b KvRKg© evavMÖ¯’ nIqv ¯^vfvweK cÖwZwµqvi Ask, hLb Zv mvs¯‹…wZK ixwZi g‡a¨ _v‡K| » `xN©vwqZ Zxeª †kvKRwbZ †ivM ev` w`b: e¨w³i g‡a¨ `xN©vwqZ Zxeª †kvK †`Lv w`‡Z cv‡i, j¶Ymg~‡ni g‡a¨ g„Z e¨w³‡K wb‡q Avweó fve ev Zb¥qZv Ges g„Z evw³i cÖwZ Zxeª AvKv•ÿv, Mfxi gvbwmK hš¿Yv I ˆ`bw›`b KvRK‡g© mgm¨v ˆZwi nq Kgc‡¶ 6 gvm a‡i (Ges mgvR-ms¯‹…wZ KZ©„K †kvK cvj‡bi mg‡qi †P‡q †ewk †gqv‡`) _v‡K| e¨e¯’v MÖn‡Yi Rb¨ GKRb we‡kl‡Ái mv‡_ Av‡jvPbv Kiæb| A¨v‡mm‡g›U cÖkœ 3: GKB mv‡_ gvbwmK, ¯œvqy yweK ev †bkv ª`e¨ e¨envi RwbZ mgm¨v (MNS) Av‡Q wK, †h Rb¨ e¨e¯’v MÖnY Kiv cÖ‡qvRb? » wb‡R‡K AvNvZ Kivi wPšÍv ev AvZ¥nZ¨vi cwiKíbv g~j¨vqb Kiæb (>> SUI)| » A¨vj‡Kvnj ev †bkv`ª‡e¨i ¶wZKi e¨envi g~j¨vqb Kiæb (>> SUB)| » hw` GKB mv‡_ GgGbGm Ae¯’v †`Lv hvq, Z‡e GKB mv‡_ GB Ae¯’v Ges gvSvwi-¸iæZi welYœZvRwbZ †iv‡Mi Rb¨ wPwKrmv wbb| 7 This description of moderate-severe depressive episode is consistent with the current draft ICD-11 proposal. g~j wPwKrmv cwiKíbv g‡bvmvgvwRK B›Uvi‡fbkb 1. mvB‡Kv GWz‡Kkb w`b » e¨w³ I Zuvi hZœKvixi Rb¨ cÖavb evZ©vmg~n:  welYœZv GKwU AwZ mvaviY Ae¯’v, GwU †h Kv‡iv n‡Z cv‡i| welYœZv nIqv gv‡bB e¨w³ y`e©j ev Ajm, GgbUv bq|  Av‡kcv‡ki †jvKR‡bi †bwZevPK „`wófw½ (†hgb- †Zvgvi Av‡iv k³ nIqv DwPZ, GKmv‡_ Kv‡R †b‡g co) †_‡K Ggb g‡b nIqv ¯^vfvweK †h, welYœZv †Kvb mvaviY NUbv bq| wbQK wb‡Ri B”Qv _vK‡jB welYœZv KvwU‡q IVv hvq, Ggb fzj aviYvI †bwZevPK `„wófw½ †_‡K Rb¥ †bq|  welYœZvq AvµvšÍ e¨w³‡`i g‡a¨ Zv‡`i wb‡R‡`i, wb‡R‡`i Rxeb ev fwel¨r wb‡q Aev¯Íe †bwZevPK aviYv †cvl‡Yi cÖeYZv †`Lv hvq| Zuv‡`i eZ©gvb Ae¯’v nq‡Zv A‡bK `ywe©ln, Z‡e welYœZvi cwiYwZ wn‡m‡e nZvkv I Rxeb‡K g~j¨nxb g‡b Kivi gZ A‡hŠw³K wPšÍv Rb¥ wb‡Z cv‡i| welYœZv `~i nIqvi mv‡_ mv‡_ Gme „`wófw½i cwieZ©b †`Lv †`q|  GgbwK hw` GUv KwVb nq, Z‡e Zvu‡`i wb‡R‡`i gvbwmK Ae¯’vi DbœwZi Rb¨ wb‡Pi KvR¸‡jv hZUv m¤¢e Kiv cÖ‡qvRb, ▸ †hme KvR c~‡e© Avb›``vqK wQj Zv cybivq ïiæ Kivi (ev Pvwj‡q hIqvi) †Póv Kiæb| ▸ wbqwgZ GKB mg‡q Nygv‡Z hvIqv Ges Nyg n‡Z IVvi †Póv Kiæb Ges Zv Ae¨vnZ ivLyb| ▸ hZUv m¤¢e kvixwiKv‡e mwµq _vK‡Z †Póv Kiæb| ▸ iæwPi cwieZ©b m‡Z¡I wbqwgZ LvIqvi †Póv Kiæb| ▸ wek¦¯Í eÜy I cwiev‡ii m`m¨‡`i mv‡_ mgq KvUv‡bvi †Póv Kiæb| ▸ KwgDwbwU ev wewfbœ mvgvwRK Kv‡R hZUzKz m¤¢e Ask MÖn‡Yi †Póv Kiæb|  e¨w³‡K Aek¨B wb‡R‡K AvNvZ ev AvZ¥nZ¨vi wPšÍv m¤c‡K© m‡PZb _vK‡Z n‡e| Zuviv hw` Ggb wPšÍv m¤ú‡K© Rvbvq, Z‡e Zuviv †m Abyhvqx KvR bv K‡i wek¦¯Í KvD‡K Rvbvb Ges Awej‡¤^ mvnv‡h¨i Rb¨ wd‡i Av‡mb| 2. gvbwmK Pvc Kgv‡bv Ges mvgvwRK mnvqZv kw³kvjxKi‡Yi g~jbxwZ Abyhvqx g‡bvmvgvwRK mnvqZv w`b (>> †mevi mvaviY g~jbxwZ) » eZ©gvb gvbwmK Pv‡ci welq¸‡jvi cÖwZ jÿ¨ Kiæb| » mvgvwRK mnvqZv evovb|  e¨w³i c~‡e©i mvgvwRK †bUIqvK©¸‡jv cybivq mPj Kivi †Póv Kiæb| c~‡e©i wewfbœ mvgvwRK KvR wPwýZ Kiæb, hw` cybivq ïiæ K‡ib, Z‡e hv cÖZ¨¶ ev c‡iv¶ Dcv‡q mvgvwRK mg_©b cÖ`vb K‡i| (†hgb- cvwievwiK wgjb, cÖwZ‡ekx‡`i m‡½ mvÿvZ, mvgvwRK KvR) » gvbwmK Pvc e¨e¯’vcbv †kLvb| 3. hw` cÖwkw¶Z I ZË¡veavbcÖvß †_ivwc÷ cvIqv hvq, Z‡e gvSvwi-¸iæZi welYœZv RwbZ †iv‡M AvµvšÍ e¨w³‡K wb‡Pi †h‡Kv‡bv GKwU msw¶ß g‡bv‰eÁvwbK wPwKrmv wb‡Z DrmvwnZ Kiæb| » mgm¨v mgvav‡bi Rb¨ KvD‡Ýwjs » KM‡bwUf-we‡nweqvi †_ivwc (wmwewU) » B›Uvi-cv‡m©vbvj ev AvšÍtcvi¯cwiK †_ivwc (AvBwcwU) » we‡nweivj GKwU‡fkb ev AvPi‡Yi mwµqKiY †_ivwc Ggb A‡bK cÖgvY Av‡Q, †hLv‡b cÖwkw¶Z I ZË¡veavbcÖvß mvaviY / KwgDwbwU Kg©x‡`i gva¨‡g welYœZvi mswÿß g‡bv‰eÁvwbK wPwKrmv †`qv †h‡Z cv‡i| 31 dvg©v‡KvjwRK¨vj wPwKrmv 1. A¨vw›UwW‡cÖm¨v›Um w`‡q wPwKrmv » 12 eQ‡ii Kg eqmx wkï‡`i †ÿ‡Î: A¨vw›UwW‡cÖm¨v›Um †`‡eb bv| » 12-18 eQi eqmx wK‡kvi-wK‡kvix‡`i †ÿ‡Î:  wPwKrmvi cÖ_g av‡cB A¨vw›UwW‡cÖm¨v›Um †`‡eb bv| cÖ_‡g g‡bvmvgvwRK wPwKrmv w`b| » cÖvßeq¯‹‡`i †¶‡Î:  hw` GKB mv‡_ A‡bK¸‡jv kvixwiK mgm¨v _v‡K, hv welYœZvRwbZ †iv‡Mi (>> g~j¨vqb cÖkœ 2) gZ g‡b n‡Z cv‡i, †m‡ÿ‡Î G¸‡jvi wPwKrmvB cÖ_‡g Kivb| A¨vw›UwW‡cÖm¨v›Um ZLbB †`qvi K_v we‡ePbv Ki‡Z cv‡ib, hLb kvixwiK mgm¨v wPwKrmvi ciI welYœZvi DbœwZ bv nq|  hw` Avcbvi g‡b nq †h, j¶Y¸‡jv eo ai‡bi ¶wZi ¯^vfvweK cÖwZwµqv (>> g~j¨vqb cÖkœ 2), Zvn‡j A¨vw›UwW‡cÖm¨v›Um †`‡eb bv|  A¨vw›UwW‡cÖm¨v›Um †`‡eb wK-bv, †m wel‡q e¨w³i mv‡_ Av‡jvPbv K‡i GKmv‡_ wm×všÍ wbb| e¨vL¨v Kiæb: ▸ A¨vw›UwW‡cÖm¨v›Um Avmw³ ˆZwi K‡i bv| ▸ †cÖwmwµckb Abyhvqx cÖwZw`b Ilya LvIqv LyeB ¸iæZ¡c~Y©| ▸ Ilya MÖn‡Yi cÖ_g wKQz w`‡bi g‡a¨ wKQz cvk¦ ©cÖwZwµqv (>> †Uwej wWBwc 1) †`Lv w`‡Z cv‡i, wKš‘ Zv Avevi Ggwb‡ZB wVK n‡q hvq| ▸ g‡bi Ae¯’v, AvMÖn ev kw³i DbœwZ n‡Z mvaviYZt K‡qK mßvn jv‡M, GUvI Rvwb‡q ivL‡Z cv‡ib|  my¯’ †eva Kivi ci 9-12 gvm A¨vw›UwW‡cÖm¨v›U Ilya MÖnY Kiv cÖ‡qvRb|  wKQz DbœwZ †`‡LB Ilya eÜ K‡i †`qv DwPZ bq (GwU gv_v e¨_vi Ily‡ai gZ bq)| e¨w³‡K D‡jøwLZ mgq Abyhvqx Ilya LvIqvi e¨vcv‡i civgk© w`b| 2. hw` A¨vw›UwW‡cÖm¨v›Um †`qvi e¨vcv‡i wm×všÍ nq, Z‡e Dchy³ A¨vw›UwW‡cÖm¨v›Um cQ›` Kiæb (>> †Uwej wWBwc 1) » A¨vw›UwW‡cÖm¨v›Um welYèZv we‡ivax Ilya wba©viY/cQ‡›`i †¶‡Î †ivMx/e¨w³i eqm, eZ©gvb kvixwiK Ae¯’v Ges cvk¦cÖwZwµqv BZ¨vw` w`K we‡ePbvq ivL‡Z n‡e| » eqtmÜxKvjxb 12 eQi ev Zvi †_‡K †ewk eqmx wK‡kvi-wK‡kvix‡`i †ÿ‡Î:  d¬yA‡·wUb (fluoxetine) (wKš‘ Ab¨ †Kvb evQvBK…Z wm‡ivwbb wiAvc‡UK BbwnweUim (GmGmAviAvB) A_ev UªvBmvBwK¬K A¨vw›UwW‡cÖm¨v›Um (wUwmGGm) w`‡Z cv‡ib, †KejgvÎ hLb g‡bvmvgvwRK wPwKrmv m‡Z¡I DcmM©/jÿY eRvq _v‡K A_ev Lviv‡ci w`‡K hvq| » Mf©eZx I ey‡Ki y`a LvIqv‡bv gv‡q‡`i †¶‡Î:  m¤¢e n‡j A¨vw›UwW‡cÖm¨v›Um w`‡eb bv| hw` g‡bvmvgvwRK wPwKrmvq DbœwZ bv nq, Z‡e ¯^íZg Kvh©Kix gvÎvq A¨vw›UwW‡cÖm¨v›Um †`qv †h‡Z cv‡i| ey‡Ki y`a LvIqv‡bv gv‡q‡`i †ÿ‡Î d¬yA‡·wUb w`‡eb bv| m¤¢e n‡j we‡kl‡Ái civgk© wbb| » eq¯‹ gvby‡li †¶‡Î:  hw` m¤¢e nq, GwgwUªcwUjvBb (amitriptyline) w`‡eb bv| » ü`‡ivMx‡`i †¶‡Î:  GwgwUªcwUjvBb w`‡eb bv| » hv‡`i AvZ¥nZ¨vi wPšÍv ev cwiKíbv Av‡Q, Ggb cÖvßeq¯‹‡`i †ÿ‡Î:  d¬yA‡·wUb (fluoxetine) cÖ_g cQ‡›` ivL‡Z n‡e| hw` wb‡R‡K AvNvZ Kivi ev AvZ¥nZ¨vi SzuwK _v‡K, †m‡ÿ‡Î Zv‡`i‡K mxwgZ A¨vw›UwW‡cÖm¨v›Um mieivn Kiæb (D`vniY¯^iƒc, GKev‡i GK mßv‡ni mieivn| †mevKvix‡K Ilya ivL‡Z ejyb Ges Zv wVKg‡Zv LvIqv n‡”Q wK-bv ch©‡eÿY Kiæb) Ges †ewk gvÎvq Ilya †meb †_‡K †invB †c‡Z evievi d‡jvAvc Kiv| †Uwej wWBwc 1: A¨vw›UwW‡cÖm¨v›Um a Available in the Interagency Emergency Health Kit (WHO, 2011) b TCA indicates tricyclic antidepressant c SSRI indicates selective serotonin reuptake inhibitor d Minimum effective dose in adults: 75 mg (sedation may be seen at lower doses). A¨wgwUªcwUjvBb (wUwmG) d¬zA‡·wUb (GmGmAviAvB) cÖvßeq¯‹‡`i Rb¨ cÖviw¤¢K †WvR iv‡Z †kvevi mgq 20-25 wg.MÖv| 10 wg.MÖv. w`‡b GKevi| GK mßvn ci 20 wg.MÖv. K‡i wK‡kvi-wK‡kvix‡`i Rb¨ cÖviw¤¢K †WvR cÖ‡hvR¨ bq (wK‡kvi-wK‡kvix‡`i wUwmG wjL‡eb bv) 10 wg.MÖv. w`‡b GKevi eq¯‹ I kvixwiK Amy¯’‡`i Rb¨ cÖviw¤¢K †WvR iv‡Z †kvevi hvIqvi mgq 25 wg. MÖv.| 10 wg.MÖv. w`‡b GKevi cÖvßeq¯‹‡`i †Wv‡Ri cwigvY e„w× cÖwZ mßv‡n 20-25 wg.MÖv. e„w× Kiæb 6 mßvn c‡i †Kvb DbœwZ bv n‡j 40 wg.MÖv. mßv‡n GKevi cÖvßeq¯‹‡`i Rb¨ Kvh©Kix Av`k© †WvR 100-150 wg.MÖv. (m‡e©v”P gvÎv 300 wg.MÖv.) 20-40 wg.MÖv (m‡e©v”P 80 wg.MÖv.) eqtmwÜÿ‡Yi wK‡kvi-wK‡kvix, e„× I Amy¯’‡`i Rb¨ Kvh©Kix Av`k© †WvR 50-75 wg.MÖv. (m‡e©v”P gvÎv 100 wg.MÖv) wK‡kvi-wK‡kvix‡`i GB Ilya †`‡eb bv 20 wg.MÖv (m‡e©v”P 40 wg.MÖv.) gvivZ¥K I K`vwPr †`Lv hvq Ggb cvk¦© cÖwZwµqv KvwW©qvK A¨vwi`wgqv `xN©‡gqv`x GKvw_wmqv, A¯^vfvweK i³cvZ mvaviY cvk¦ ©cÖwZwµqv gv_v †Nvivq, wSgvq, gyL ïwK‡q hvIqv, †KvôKvwVb¨, cÖmªv‡e mgm¨v, NygNyg, Svcmv „`wó, w ’¯iZv gv_v e¨_v, Aw ’¯iZv, fq, cwicv‡K mgm¨v, †hŠb mgm¨v mZK©Zv hw` g¨wbK Gwc‡mvW †`Lv †`q, Z‡e Zvr¶wYK Ilya eÜ K‡i w`b hw` g¨wbK Gwc‡mvW ˆZwi nq, Z‡e Zvr¶wYK Ilya eÜ K‡i w`b 3. d‡jv-Avc » wbqwgZ d‡jv-Avc w`b ◆ wPwKrmv bxwZ Abyhvqx wbqwgZ d‡jv-Avc †mkb wba©viY Ges cwiPvjbv Kiæb (>> h‡Zœi mvaviY bxwZ)| ◆ wØZxq Ac‡q›U‡g›U GK mßv‡ni g‡a¨ wbb Ges cieZ©x A¨vc‡q›U‡g›U¸‡jv †iv‡Mi aib ey‡S| » A¨vw›UwW‡cÖm¨v‡›Ui djvdj jÿ¨ Kiv ◆ A¨vw›UwW‡cÖm¨v‡›Ui djvdj †c‡Z K‡qK mßvn jvM‡Z cv‡i| †WvR evov‡bvi Av‡M mZK©Zvi mv‡_ cÖwZwµqv ch©‡eÿY Kiæb| ◆ hw` g¨vwbK Gwc‡mv‡Wi jÿY ˆZwi nq (>> A¨v‡mm‡g›U cÖkœgvjv 2), Z‡e Awej‡¤^ A¨vw›UwW‡cÖm¨v›U Ilya eÜ K‡i w`b Ges g¨vwbK Gwc‡mvW wPwKrmvq >> PSY gwWD‡j hvb| ◆ jÿY¸‡jv fv‡jv nIqvi 9-12 gvm ci Ilya Kgv‡bvi K_v we‡ePbv Kiæb| AšÍZ: 4 mßvn a‡i µgvš^‡q †WvR Kgvb| D E P †Uwej wWBwc 2 : evB‡cvjvi wWmAW©v‡i gyW ÷vwejvBRvi Kvievgv‡RcvBb f¨vj‡cÖv‡qU ïiæi †WvR 200 wgwjMÖvg/w`b 400 wg.MÖv. w`‡b Av`k© Kvh©Kix †WvR 400-600 wg.MÖv./w`b (m‡e©v”P gvÎv 1400 wg.MÖv./w`b) 1000-2000 wg.MÖv./w`‡b m‡e©v”P 2500 wg.MÖvg./w`‡b †WvwRs wkwWDj w`‡b y`Õevi, gy‡L w`‡b y`Bevi, gy‡L K`vwPr †`Lv hvq, Z‡e ¸iæZi cvk¦©cÖwZwµqv ◆ Z¡‡K Zxeª dzmKzwo (w÷‡fbm&-Rbmb wmb‡Wªvg*, Uw·K GwcWvigvj wb‡µvjvBwmm ◆ Aw¯’ g¾vi Drcv`b e¨nZ n‡”Q/†evb g¨v‡iv wW‡cÖkb* ◆ Z›`ªv”Qbœ fve ◆ weåvšÍ nIqv mvaviY cvk¦©cÖwZwµqv ◆ Z›`ªv”Qbœ fve ◆ Pjv‡divq ev nuvU‡Z Amyweav ◆ ewg ewg fve ◆ wSgywb ev K¬vwšÍ ◆ Aby‡ËwRZ ◆ kixi Kvucv ◆ ewg ewg fve, Wvqwiqv ◆ IRb †e‡o hvIqv ◆ mvgwqK Pzj c‡o hvIqv (mvaviYZ 6 gv‡mi g‡a¨ Avevi MRvq) ◆ †ncvwUK dvskb bó n‡q hvIqv e· wWBwc 2 : evB‡cvjvi wWmAW©v‡ii eZ©gvb welYœZv Gwc‡mv‡Wi †ÿ‡Î wPwKrmv e¨e ’¯v evB‡cvjvi wWmAW©v‡ii e¨w³‡`i KL‡bv gyW ÷vwejvBRvi Qvov ïaygvÎ A¨vw›UwW‡cÖm¨v›U †`qv hv‡e bv, KviY A¨vw›UwW‡cÖm¨v›U g¨vwbK Gwc‡mvW ˆZwi Ki‡Z cv‡i| hw` g¨vwbK Gwc‡mv‡Wi BwZnvm †_‡K _v‡K: » GKRb we‡kl‡Ái civgk© wbb| » hw` ZvrÿwYKfv‡e we‡klÁ bv cvIqv hvq, Z‡e gyW ÷vwejvBRvimn A¨vw›UwW‡cÖm¨v›U w`b, †hgb- Kvievgv‡RcvBb ev f¨vj‡cÖv‡qU (>>‡Uwej wWBwc 2) ◆ Kg †WvR w`‡q Ilya ïiæ Kiæb| c‡ii mßvn¸‡jv‡Z ax‡i ax‡i evovb| ▸ hw` m¤¢e nq, Mf©eZx ev hviv Mf© avi‡Yi wPšÍv Ki‡Qb, Zv‡`i Rb¨ Kvievgv‡RcvBb ev f¨vj‡cÖv‡qU Ilya w`‡eb bv, KviY GB Ilya åæ‡Yi h‡_ó ÿwZ Ki‡Z cv‡i| gyW ÷vwejvBRvi ïiæ Kivi †ÿ‡Î Mf©eZx gwnjvi mv‡_ Av‡jvPbvi gva¨‡g wm×všÍ wb‡Z n‡e| g¨vwbK I welYœZv Gwc‡mv‡Wi ZxeªZv Ges KZevi NU‡Q, Zv we‡ePbvq wb‡Z n‡e| ◆ evB‡cvjvi wWmAW©v‡ii Pjgvb wPwKrmv wb‡q GKRb we‡kl‡Ái civgk© wbb » hw` M‡f©i ev”Pvi g‡a¨ g¨vwbK Gwc‡mv‡Wi jÿY ˆZwi nq, Zvn‡j Zv‡K Ges Zvi hZœKvix‡K ejyb Awej‡¤^ A¨vw›UwW‡cÖm¨v›U eÜ K‡i w`‡Z Ges mvnv‡h¨i Rb¨ wd‡i Avm‡Z| 33 †cv÷-UªgvwUK PTSD †÷ªm wWmAW©vi Zxeª gvbwmK Pvc (GwmBD) gwWD‡j D‡jøL Kiv n‡q‡Q, †Kvb Riæwi gvbweK cwiw ’¯wZ‡Z Zxeª gvbwmK Pv‡ci ci cÖvßeq¯‹, wK‡kvi-wK‡kvix I wkï‡`i gv‡S mvaviYZt e¨vcK gvbwmK cÖwZwµqv A_ev j¶Y †`Lv †`q| AwaKvsk gvby‡li †ejvq, GB j¶Y¸‡jv ¶Y ’¯vqx nq| †Kvb m¤¢ve¨ UªgvwUK NUbvi ci hLb GKwU wbw ©`ó ˆewk‡ó¨i A‡bK¸‡jv j¶Y (cybtAwfÁZv, Gwo‡q Pjv I eZ©gvb SzuwK wb‡q Lye †ewk AvZw¼Z nIqv) GK gv‡mi †ewk mgq a‡i Pj‡Z _v‡K, ZLb e¨w³i gv‡S †cv÷-UªgvwUK †÷ªm wWmAW©vi (wcwUGmwW) ˆZwi n‡Z cv‡i| GB bvg m‡Z¡I wcwUGmwW-B GKgvÎ ev cÖavb Ae ’¯v bq, hv m¤¢ve¨ UªgvwUK NUbvi ci N‡U| GB ai‡bi NUbv Ab¨vb¨ gvbwmK, ¯œvqweK I †bkv ª`e¨ e¨envi msµvšÍ ˆZwi Ki‡Z cv‡i, hv GB wb‡ ©`wkKvq eY©bv Kiv n‡q‡Q| wcwUGmwW ˆewkó¨c~Y© Dc ’¯vcb wcwUGmwW AvµvšÍ e¨w³‡K Ab¨vb¨ mgm¨vq AvµvšÍ‡`i †_‡K Avjv`v Kiv KwVb, †Kbbv cÖv_wgKfv‡e Zviv Awbw`©ó j¶Y Dc¯’vcb K‡ib, †hgb: » Ny‡gi mgm¨v (†hgb, Kg Nyg nIqv) » wei³, ’¯vqx DwØMœ ev welYœ gb » ¯úó KviY QvovB GKvwaK ’¯vqx kvixwiK DcmM© (†hgb- g¨v_ve¨_v, ü`wc‡Ði aodovwb)| Z‡e, AviI wRÁvmvev‡`i gva¨‡g †ei n‡q Avm‡Z cv‡i †h Zviv wcwUGmwW jÿ‡Y fyM‡Q| 35 A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1t 1 gv‡mi AwaK mgq c~‡e© e¨w³wU wK UªgvwUK NUbvi wkKvi n‡q‡Q? » wR‡Ám Kiæb, e¨vw³wU †Kvb UªgvwUK NUbvi wkKvi wK-bv| GUv †h †Kvb ai‡bi ûgwKi ev fqvbK NUbv, †hgb- kvixwiK ev †hŠb wbh©vZb (cvwievwiK mwnsmZvI n‡Z cv‡i), b„mskZvi `„k¨ †`Lv, Nievwo aŸsm nIqv, wKsev †Kvb eo ai‡bi y`N©Ubv ev ÿqÿwZ| wR‡Ám Kiæbt ◆ wech©q ev msNv‡Z Avcwb wKfv‡e ÿwZMÖ Í¯? Avcbvi Rxeb wK SzuwKi g‡a¨? N‡i ev KwgDwbwUi g‡a¨ Avcwb wK Ggb wKQz †`‡L‡Qb, †hUv fxlY AvZ‡¼i ev f‡qi ev Lvivc Abyf~wZi? » hw` e¨w³wU UªgvwUK NUbvi wkKvi n‡q _v‡K, wR‡Ám Kiæb, NUbvwU K‡e N‡UwQj| A¨v‡mm‡g›U cÖkœ 2t hw` 1 gvm Av‡M UªgvwUK NUbv N‡U _v‡K, Z‡e Zvi wK wcwUGmwW Av‡Q?8 » hvPvB Kiæbt ◆ DcmM©mg~‡ni cybive„wË| G¸‡jv nj NUbvi cybive„wË I AevwÃZ ¯§„wZ, †hb g‡b nq, NUbvwU GLb GLv‡bB NU‡Q (D`vniY¯^iƒc, fqsKi ¯^cœ, ¯§„wZ †ivgš’b*, ev Mfxi fq I fxwZKi AbvûZ ¯§„wZ)| ▸ wkï‡`i †ÿ‡Î NUbv¸‡jv Zviv evievi ¯§iY K‡i ev AsKb K‡i| Aíeq¯‹ wkïiv cwi®‹vi welqe ‘¯ QvovB fqsKi ¯^cœ †`L‡Z cv‡i| ◆ Gwo‡q Pjv DcmM©mg~n| G¸‡jv nj †mB me wPšÍv, ¯§„wZ, KvRKg© ev cwiw ’¯wZ B”QvK…Zfv‡e Gwo‡q Pjv, †h¸‡jv e¨w³‡K †mB NUbv g‡b Kwi‡q †`q| (†hgb, Ggb me welq wb‡q K_v ej‡Z bv PvIqv, †h¸‡jv Zv‡K NUbv g‡b Kwi‡q †`q, wKsev NUbv ’¯‡j hvIqv †_‡K weiZ _vKv)| ◆ eZ©gvb wec‡`i Zxeª Abyf~wZ msµvšÍ DcmM©mg~n (†hUv‡K cÖvqB ejv nq ÒnvBcviGivDRvj wm¤úUgmÓ)| G¸‡jv n‡q _v‡K wec` †_‡K evuPvi Rb¨ AwZwi³ D‡ØM I mZK©Zv wKsev D”P k‡ã ev AcÖZ¨vwkZ AvPiY (†hgb, jvd w`‡Z hvIqv ev †Kvb wKQzi wKbv‡i hvIqv)| ◆ wbZ¨w`‡bi KvRKg© mva‡b h‡_ó mgm¨v ˆZwi nIqv| » NUbvi AvbygvwbK 1 gvm c‡i hw` Dc‡ii cÖwZwU welqB Dcw¯’Z _v‡K, Zvn‡j wcwUGmwW _vKvi m¤¢vebv i‡q‡Q| A¨v‡mm‡g›U cÖkœ 3t GKB mv‡_ Avi †Kvb mgm¨v Av‡Q wK? » GKmg‡q †Kvb kvixwiK mgm¨v, hv wcwUGmwWi jÿY w`‡q e¨vL¨v Kiv hvq, Zv Av‡Q wKbv A¨v‡mm‡g›U/wba©viY Kiæb I e¨e ’¯v wbb| » me GgGGbGm Ae ’¯v hvPvB Kiæb Ges wPwKrmv/cwiPh©v cÖ` vb Kiæb, †hUv GB wb‡`©kvbvq ejv n‡q‡Q| | 8 The description of PTSD is consistent with the current draft ICD-11 proposal for PTSD, with one difference: the ICD-11 proposal allows for classification of PTSD within 1 month (e.g. several weeks) after the event. The ICD-11 proposal does not include non-specific PTSD symptoms such as numbing and agitation. g~j wPwKrmv cwiKíbv 1. wcwUGmwW m¤ú‡K© wkÿv cÖ`vb Kiæb » e¨vL¨v Kiæbt ◆ wKQz gvbyl mg‡qi mv‡_ mv‡_ wPwKrmv QvovB wcwUGmwW †_‡K my¯’Zv jvf K‡i, Avevi Ab¨‡`i †ÿ‡Î wPwKrmvi cÖ‡qvRb nq| ◆ wcwUGmwW‡Z AvµvšÍ e¨w³iv Awb”Qv m‡Ë¡I evievi †mB ¯§„wZ g‡b Ki‡Z _v‡K, †hwU Zv‡K fxlYfv‡e gvbwmK AvNvZ w`‡q‡Q| hLb GUv N‡U, ZLb Zviv Abyf~wZ¸‡jv- †hgb, fq I AvZ¼ Abyfe Ki‡Z cv‡i, wVK †hgbwU Zviv NUbvwU NUvi mgq K‡iwQj| Zviv fq¼i me ¯^cœI †`L‡Z cv‡i| ◆ wcwUGmwW †Z AvµvšÍ e¨w³iv cÖvqB fv‡e †h, Zviv GLbI wec‡`i g‡a¨ Av‡Q Ges fxlY wPwšÍZ Ae¯’vq _v‡K| Zviv Lye mn‡R PwKZ (jvwd‡q IVv) wKsev mve©ÿwYK wec‡`i Rb¨ AwZwi³ mZK© n‡q _v‡K| ◆ wcwUGmwW AvµvšÍ e¨w³iv †mme welq Gwo‡q Pj‡Z Pvq, †h¸‡jv Zv‡K †mB NUbvwU ¯§iY Kwi‡q †`q| Gai‡bi Gwo‡q Pjvi cÖeYZv Zv‡`i Rxe‡b bvbv mgm¨vi m„wó K‡i| ◆ (cÖ‡hvR¨ n‡j), wcwUGmwW †Z AvµvšÍ e¨w³iv Ab¨vb¨ kvixwiK I gvbwmK mgm¨vqI †fv‡M| †hgb, kix‡ii wewfbœ As‡k e¨v_v, y`e©jZv, K¬vwšÍ, gvbwmK welYœZv I wLUwL‡U fve| » e¨w³wU‡`i civgk© w`b †h: ◆ hZLvwb m¤¢e Zviv †hb Zv‡`i ¯^vfvweK Rxeb hvcb wVK iv‡L| ◆ wK N‡UwQj Ges Zviv †Kgb Abyfe K‡i, †mm¤ú‡K© Zv‡`i wek¦¯Í gvby‡li mv‡_ †hb Avjvc K‡i; Aek¨B ïaygvÎ ZLbB, hLb Zviv wb‡R‡`i‡K cÖ¯‘Z e‡j g‡b K‡i| ◆ D‡ØM I wPšÍv Kgv‡bvi Rb¨ Ggb meKv‡R wbhy³ _vKzK, †h¸‡jv Avivg †`q| ◆ wcwUGmwW DcmM© †gvKv‡ejvi Rb¨ G¨vj‡Kvnj ev gv`K MÖnY †_‡K †hb weiZ _v‡K| 2. g‡bvmvgvwRK mnvqZv w`b †hfv‡e gvbwmK Pvc Kgv‡bv I mvgvwRK mnvqZv e„w×i g~jbxwZ‡Z ejv n‡q‡Q (>>†Rbv‡ij wcÖwÝcvjm Ad †Kqvi)Gi eY©bvb ymv‡i g‡bvmvgvwRK mnvqZvi cÖ Í¯ve w`b » eZ©gvb g‡bvmvgvwRK Pv‡ci KviY¸‡jv wPwýZ Kiæb| ◆ e¨w³wU e¨vcK gvbevwaKvi j•N‡bi wkKvi n‡j, Zv‡`i mv‡_ m¤¢ve¨ wek¦¯Í †Kvb myiÿv †K› ª` ev gvbevwaKvi ms ’¯vq cvVv‡bv wb‡q Av‡jvPbv Kiæb| » mvgvwRK mnvqZv¸‡jv gReyZ Kiæb| » Pvc †gvKvwejv m¤ú‡K© wkÿv w`b| 3. hw` cÖwkÿYcÖvß Ges ZË¡veav‡bi AvIZvq _vKv †_ivwc÷ bvMv‡ji g‡a¨ _v‡K, Z‡e Gme civgk© †`qvi K_v wPšÍv Kiæbt » Uªgv †dvKvm K‡i KMwbwUf we‡nwfqvi †_ivwc*| » AvB gyyf‡g›U wW‡mwÝUvB‡Rkb GÛ wicÖ‡mwms (BGgwWAvi)*| 4. hw` KMwbwUf we‡nwfqvivj †_ivwc, BGgwWAvi wKsev †÷ªm g¨v‡bR‡g›U KvR bv K‡i wKsev Gai‡bi †mev cvIqv bv hvq, Z‡e cÖvßeq¯‹‡`i‡K A¨vw›UwW‡cÖm¨v›Um (wm‡jw±f †m‡iv‡Uvwbb wiAvc‡UK BbwnweUim wKsev UªvBmvBwK¬K A¨vw›UwW‡cÖm¨v›Um) †`qv †h‡Z cv‡i » A¨vw›UwW‡cÖm¨v›U †cÖmµvBe Kivi wel‡q we¯ÍwiZ wb‡`©kbv †c‡Z gvSvix-¸iæZi welYœZv welqK gwWD‡ji mvnvh¨ wbb (>> wWBwc)| w`‡eb bv| 5. d‡jv-Avc » e¨e ’¯vcbvi bxwZ Abyhvqx wbqwgZ d‡jv-Avc †mk‡bi e¨e ’¯v Kiæb (>> mvaviY †mev bxwZ hZœ bxwZ)| gvÎvi Dci wbf©i K‡i wkwWDj Kiæb| » wkï I AcÖvßeq¯‹‡`i wcwUGmwW e¨e ’¯vcbvq KLbB Gw›UwW‡cÖ‡m›U Ilya †`‡eb bv| » 2-4 mßv‡ni g‡a¨ wØZxq mvÿvrKv‡ii e¨e ’¯v Kiæb Ges cieZ©x Ac‡q›U‡g›U¸‡jv Amy¯’Zvi Ici wbf©i K‡i| 29 37 39 mvB‡Kvwmm mvB‡Kvwm‡m AvµvšÍ cÖvßeq¯‹ I wK‡kvi-wK‡kvixiv Ggb wKQz wek¦vm K‡i ev AwfÁZv jvf K‡i, hv ev ͯe bq| Zv‡`i wek¦vm I AwfÁZv¸‡jv mvaviYZt KwgDwbwU‡Z A¯v^fvweK e‡jB we‡ewPZ nh| mvB‡Kvwm‡m AvµvšÍ e¨w³ cÖvqB Zv‡`i gvbwmK ¯v^ ’¯¨ m¤ú‡K© Am‡PZb _v‡Kb| Rxe‡bi A‡bK †ÿ‡Î Zviv ¯^vfvweKfv‡e KvR Ki‡Z cÖvhB Aÿg _v‡Kb| Riæwi gvbweK cwiw¯’wZ‡Z Pig gvbwmK Pvc I fq, mvgvwRK mnvqZv †f‡O cov Ges ¯v^ ’¯¨‡mev cwi‡lev ev Ilya mieivn evavMÖ ’¯ n‡Z cv‡i| GB cwieZ©b Zxeª mvB‡Kvwm‡mi KviY n‡Z cv‡i A_ev Av‡M †_‡KB we`¨vgvb mvB‡Kvwm‡mi DcmM©¸‡jv Av‡iv evov‡Z cv‡i| Avc`Kvjxb mg‡q mvB‡Kvwm‡m AvµvšÍ e¨w³iv wewfbœ gvbevwaKvi j•N‡bi gva¨‡g Pig ÿwZMÖ Í¯ nb, †hgb- Ae‡njv, cwiZ¨³ Kiv, M„nnxb nIqv, wbh©vZb I mvgvwRK AMÖnY‡hvM¨Zv| mvB‡Kvwm‡mi Awf‡hvMmg~‡ni ˆewkó¨ A¯^vfvweK AvPiY (†hgb, A™¢yZ Aeqe, AvZ¥-Ae‡njv, AmsjMœ K_vevZ©v, D‡Ïk¨nxbfv‡e ZvwK‡q _vKv, wb‡R wb‡R weoweo Kiv ev nvmv) A™¢zZ wek¦vm Ggb wKQz †`Lv ev †kvbv hvi †Kvb Aw¯ÍZ¡ †bB Zxeª m‡›`n A‡b¨i mv‡_ _vKvi ev K_v ejvi B”Qvi Afve; cÖwZw`‡bi KvRKg© Ki‡Z Abxnv| PSY A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1: e¨w³wUi wK mvB‡Kvwmm Av‡Q? » g‡b ivL‡eb, mvB‡Kvwmm G AvµvšÍ e¨w³wUi A¯^vfvweK wPšÍv, wek¦vm ev K_vevZ©v _vK‡Z cv‡i, Zvi gv‡b GUv bq †h, wZwb hv ej‡Qb, Zv me fzj I KíbvcÖm~Z| mvB‡Kvwmm g~j¨vq‡bi g~j welq g‡bv‡hvM w`‡q †kvbv| c~Y© g~j¨vqb wbwðZ Ki‡Z GKvwaK †mk‡bi cÖ‡qvRb n‡Z cv‡i| †mev`vbKvixiv cÖvqB mnvqK Z‡_¨i Drm n‡Z cv‡i| » A¨v‡mm Kiæbt ◆ wWwjDkb* (`„p I wfwËnxb wek¦vm ev wecixZ cÖgvY _vKv m‡Z¡I m‡›`nmg~n `„pfv‡e _vKv)| ▸ civgk©: Avev‡iv wRÁvmv K‡i †ei Kiæb, e¨w³wU Avm‡j wK †evSv‡Z Pv‡”Qb, Ges Mfxi g‡bv‡hvM w`‡q ïbyb| ◆ n¨vjywm‡bkb* (ev¯Í‡e Aw¯ÍZ¡ †bB, Ggb wKQz †kvbv, †`Lv ev Abyfe Kiv) ▸ Avcwb wK Ggb wKQz †kv‡bb ev †`‡Lb, †hUv Ab¨iv cv‡i bv? ◆ wek„•Lj wPšÍv-fvebv nj †hŠw³K ms‡hvM QvovB GK welq †_‡K Av‡iK welq G P‡j hvIqv; K_v-evZ©v AbymiY Kiv KwVb| ◆ A™¢zZ AwfÁZv, †hgb- wek¦vm Kiv †h, Zvi g‡b Ab¨iv wPšÍv XzwK‡q w`‡”Q ev Zvi wPšÍv †ei K‡i wb‡q hv‡”Q, wKsev Zvi wPšÍv Ab¨‡`i Kv‡Q cÖPvwiZ n‡q hv‡”Q ◆ A¯^vfvweK AvPiY, †hgb- A¯^vfvweK, cvMjv‡U, D‡Ïk¨nxb Ges D‡ËwRZ KvRKg© wKsev A¯^vfvweK kvixwiK A½fw½ ev GKev‡iB bovPov bv Kiv ◆ `xN©Kvjxb DcmM© hv‡Z ¯^vfvweK KvRKg© webó nq, †hgb- ▸ ˆ`bw›`b KvRKg© Kivi kw³ ev B”Qvi Afve ▸ J`vwmb¨ I mvgwRK wew”QbœZv ▸ wb‡Ri cÖwZ h‡Zœi Afve ev Ae‡njv ▸ Av‡eMxq AwfÁZv I ¯úóZvi Afve » mvB‡Kvwmm n‡Z cv‡i, hw` †ek K‡qKwU DcmM© _v‡K| me mgq ch©‡eÿY Kiæb AvZ¥nZ¨vi SzuwK (>> GmBDAvB) Ges A‡b¨i I Ab¨‡`i ÿwZi Avk¼v Av‡Q wK-bv| A¨v‡mm‡g›U cÖkœ 2: mvB‡KvwUK DcmM©mg~‡ni Ggb †Kvb Zxeª kvixwiK KviY Av‡Q wK, †h¸‡jvi e¨e¯’vcbv m¤¢e? » Zxeª kvixwiK mgm¨vi Kvi‡Y gvbwmK weåg, wKbv Zv wbwðZ †nvb| D`viniY¯^iƒc, gv_vq AvNvZ, msµgY (†hgb, †mwieªvj g¨v‡jwiqv, †mcwmm* ev BD‡iv‡mcwmm*), cvwbk~b¨Zv Ges wecvKxq A¯^vfvweKZv (†hgb- nvB‡cvMøvBwmwgqv*, nvB‡cv‡bwUªwgqv*) †iv‡Mi Kvi‡Y †Wwjwiqvg ev` w`b| » Ily‡ai cvk¦©cÖwZwµqv wKbv Zv wbwðZ †nvb (†hgb- wbw`©ó wKQz Gw›Ug¨v‡jwiqvi Ilya †_‡K)| » ev` w`b A¨vj‡Kvnj ev gv`‡Ki welwµqv/cÖZ¨vnvi (....)| ◆ wR‡Ám Kiæb A¨vj‡Kvnj, D‡ËRbv cÖkg‡bi Ilya ev Ab¨vb¨ gv`K e¨envi m¤ú‡K©| ◆ A¨vj‡Kvnj MÜ wbb| hvPvB cÖkœ 3: GUv wK GKwU g¨vwbK GwW‡mvW? » g¨vwbqv ev` w`b| hvPvB Kiæb: ◆ Ny‡gi cÖ‡qvRb K‡g hvIqv ◆ AwZAvbw›`Z, AwZ D”QjZv ev wLUwL‡U †gRvR ◆ bvbv ai‡bi wPšÍv Avmv; mn‡RB wewÿß nIqv ◆ Kg©PÂjZv †e‡o hvIqv, Kg©kw³ e„w×i Abyf‚wZ A_ev `ªæZ K_v ejv ◆ Av‡eMcÖeY ev Awbqwš¿Z AvPiY, †hgb- AwZwi³ Ryqv ev LiP Kiv, h‡_ó cwiKíbv Qvov ¸iæZ¡c~Y© wm×všÍ †bqv ◆ AšÍtmvik~b¨ Aev¯Íe AvZ¥wek¦vm| » g¨vwbK Gwc‡mvW n‡Z cv‡i hw` GK mßv‡ni †ewk mgq Gme Dcm‡M©i †ek K‡qKwU Dcw¯’Z _v‡K, Ges Gme DcmM©mg~‡ni Kvi‡Y e¨w³i ˆ`bw›`b Kv‡R mgm¨v ˆZwi K‡i A_ev evwo‡Z e¨w³‡`i‡K wbivc‡` ivLv bv hvq| 32 m vB 41 g~j wPwKrmv cwiKíbv K. dvg©v‡KvjwRKvj wUªU‡g›U (Ily‡ai gva¨‡g wPwKrmv) 1. Zxeª kvixwiK KviY †bB, Ggb mvB‡Kvwm‡mi Rb¨ » gy‡L LvIqvi Gw›UmvB‡KvwUK Ilya ïiæ Kiæb| †KejgvÎ gy‡L LvIqv‡bv m¤¢e bv n‡j Bb‡RKkb (B›UªvgvmKzjvi) we‡ePbv Kiæb| Rvbyb, e¨w³wU AZx‡Z Ggb †Kvb Gw›UmvB‡KvwUK Ilya MÖnY K‡i‡Qb wK-bv, †hUv Zvi DcmM© wbqš¿‡Y mvnvh¨ K‡i‡Q| hw` nu¨v nq, IB Ilya GKB gvÎvq Avevi ïiæ Kiæb| hw` IlyawU cvIqv bv hvq, Z‡e bZzb †Kvb Ilya ïiæ Kiæb| wPwKrmvi ïiæ‡Z Ilya msiÿY I Zv †`qvi †ÿ‡Î †mev`vbKvix ev ¯^v¯’¨Kg©xi RwoZ _vKvUv Riæwi, hv‡Z wbivc` Ilya MÖnY wbwðZ nq| ◆ GKev‡i †Kej GKwU Gw›UmvB‡KvwUK Ilya w`b (†hgb, n¨v‡jv‡cwiWj>> †Uwej mvB 1)| ◆ ÒwbP †_‡K ïiæ K‡i ax‡i ax‡i Dc‡i hvbÓ: A_©vr me©wb¤œ †_ivwcDwUK gvÎv w`‡q ïiæ Kiæb Ges me©wb¤œ Kvh©Ki gvÎvq Kvw•ÿZ dj †c‡Z ax‡i ax‡i gvÎv evovb| ◆ Ilya‡K AKvh©Ki we‡ePbvi Av‡M ch©vß mg‡qi Rb¨ Kvh©Ki gvÎvq Zv w`b (†hgb, Kgc‡ÿ 4-6 mßvn) (>> †Uwej mvB 1)| ▸ Mf©avi‡bi cwiKíbv Ki‡Qb ev Mf©eZx A_ev ey‡Ki `ya LvIqv‡”Qb, Ggb gv‡q‡`i †ÿ‡Î me©wb¤œ Kvh©Ki gvÎvi Ilya w`b| ◆ hw` ïaygvÎ GKwU Gw›UmvB‡KvwUK Ilya w`‡q wLUwL‡U †gRvR wbqš¿Y Kiv bv hvq, †m‡ÿ‡Î †eb‡RvWvqv‡Rwc‡bi GKwU †WvR w`b (†hgb, WvqvwRcvg, m‡e©v”P 5 wg.MÖv. gy‡L LvIqvi) Ges AbwZwej‡¤^ we‡kl‡Ái civgk© wbb| ◆ cvk¦©-cÖwZwµqvi e¨e¯’vcbv ▸ D‡jøL‡hvM¨ Zxeª G·UªvwcivwgWvj cvk¦© cÖwZwµqvi †ÿ‡Î* †hgb, cviwKbmwbRg (K¤úb*, †cwki `„pZv I kix‡ii bovPov n«v‡mi mgšq^) wKsev A¨vKvw_wkqv* (†mvRv n‡q em‡Z bv cviv): ∙ Gw›UmvB‡KvwUK Ily‡ai gvÎv Kwg‡q w`b| ∙ †WvR Kwg‡q †`qvi ciI hw` G·UªvwcivwgWvj cvk¦©cÖwZwµqv †_‡K hvq, Z‡e ¯^í‡gqv‡` Gw›U‡KvwjbviwRK w`‡Z cv‡ib (†hgb, 4-8 mßv‡ni Rb¨ evBcvwiWvb (>> †Uwej mvB 2)| ▸ Zxeª wWm‡Uvwbqvi (gvsm‡cwki Zxeª wLuPzwb, we‡klZ Nvo, wRnŸv I †Pvqv‡ji) †ÿ‡Ît ∙ mvgwqKfv‡e Gw›UmvB‡KvwUK Ilya eÜ K‡i w`b Ges Gw›U‡KvwjbviwR· (†hgb, evB‡cwiWvb >> †Uwej mvB 2) w`b| hw` G¸‡jv bv _v‡K, †cwki wkw_jvq‡bi Rb¨ WvqvwRcvg †`qv †h‡Z cv‡i| ◆ m¤¢e n‡j wPwKrmvi e¨vßx Ges KLb Gw›UmvB‡KvwUK Ilya eÜ Ki‡Z n‡e †m e¨vcv‡i GKRb we‡km‡Ái civgk© wbb| ▸ mvaviYZfv‡e Dcm‡M©i mgvavb nIqvi ci AšÍZ 12 gvm Gw›UmvB‡KvwUK Ilya ivLyb| ▸ Ilya eÜ Ki‡Z K‡qK gvm a‡i ax‡i ax‡i Ily‡ai gvÎv Kgvb| ▸ KLbB nVvr K‡i Ilya eÜ Ki‡eb bv| 2. Zxeª kvixwiK Kvi‡Y mvB‡KvwUK Dcm‡M©i Rb¨ (†hgb, A¨vj‡Kvnj ev` †`qv ev gv`K †bqvi d‡j weKviMÖ ’¯Zv) 6. » Zxeª KviY¸‡jvi e¨e¯’vcbv Kiæb| ◆ A¨vj‡Kvnj DB_W ªqvj e¨e¯’vcbvi Rb¨ GmBDwe gwWD‡ji 1 b¤^i e· †`Lyb| ◆ A¨vj‡Kvnj DB_WªIqvj Qvov Ab¨vb¨ Zxeª kvixwiK Kvi‡Yi †ÿ‡Î cÖ‡qvRb Abymv‡i GKwU Iivj Gw›UmvB‡KvwUK Ilya w`b (†hgb, n¨v‡jv‡cwiWj, ïiæ‡Z cÖwZ †WvR 0.5 wg.MÖv. †_‡K 2.5-5 wg.MÖv. cÖwZw`b 3 evi)| wLUwL‡U fve, mvB‡KvwUK DcmM© ev AvMÖvmb wbqš¿‡Yi cÖ‡qvRb n‡j †KejgvÎ Gw›UmvB‡KvwUK Ilya w`b| GB me DcmM© P‡j hvIqv gvÎB Ilya eÜ K‡i w`b| gy‡Li LvIqv‡bv m¤¢e bv n‡j ZLbB †Kej B›UªvgvmKyjvi Bb‡RKk‡bi K_v we‡ePbv Ki‡eb| 3. g¨vwbK GwW‡mv‡Wi Rb¨ » GKwU Iivj Gw›UmvB‡KvwUK Ilya w`‡q ïiæ Kiæb (>> #1Dc‡ii dvg©v‡KvjwRK¨vj B›Uvi‡fbk‡bi Aax‡b)| » Gw›UmvB‡KvwUK wUªU‡g›U m‡Z¡I e¨w³wU Pig D‡ËwRZ _vK‡j †eb‡RvWvqv‡Rwc‡bi (†hgb, WvqvwRcvg, m‡e©v”P 5 wg.MÖv. gy‡L LvIqvi) GKwU †WvR hy³ Ki‡Z cv‡ib Ges GKRb we‡kl‡Ái mv‡_ `ªæZ civgk© Kiæb| » g¨vwbK Gwc‡mvW nj evB‡cvjvi wWRAW©v‡ii* Ask| GKevi Zxeª g¨vwbqvi e¨e¯’vcbv Kiv †M‡j e¨w³wUi evB‡cvjvi wWRAW©v‡ii g~j¨vqb I wPwKrmv w`‡Z n‡e| G‡ÿ‡Î GKwU gyW ÷¨vwejvBRvi †hgb, fvj‡cÖv‡qU ev Kvievgv‡Rwcb w`b| e¨e¯’vcbvi Rb¨ GKRb we‡kl‡Ái civgk© wbb Ges/A_ev GgGBPM¨vc B›Uvi‡fbkb MvBW Abyhvqx evB‡cvjvi wWRAW©vi-Gi wb‡`©kbv cy‡ivcywi †g‡b Pjyb| 33 m vB †Uwej mvB 1: Gw›UmvB‡KvwUK Ilya †gwW‡Kkb n¨v‡jv‡cwiWjK †K¬vi‡cÖvg¨vwRb wim‡cwiWb ïiæi †WvR 2.5 wg.MÖv. cÖwZw`b 50–75 wg.MÖv. cÖwZw`b 2 wgMÖv cÖwZw`b wUwcK¨vj Kvh©Kix †WvR 4-10 wg.MÖv./w`b (m‡e©v”P 20 wg.MÖv. †WvR) 75–300 wg.MÖv./w`bL 4–6 wgMÖv/w`b (m‡e©v”P 1000 wgMÖv) (m‡e©v”P 10 wgMÖv) iæU Iivj/B›UªvgvmKzjvi Iivj Iivj wmMwbwd‡K›U mvBW B‡d±m: G·UªvwcivwgWvj mvBW B‡d±m* +++ + + wm‡Wmb (we‡kl K‡i eq¯‹‡`i gv‡S) + +++ + BDwibvwi †nwR‡UwÝ ++ A‡_©v÷¨vwUK nvB‡cv‡Ubkb* + +++ + wbD‡iv‡jwÞK g¨vwjMb¨v›U wmb‡Wªvg* †iqviM ‡iqviM ‡iqviM K B›UviG‡RwÝ Bgv‡R©wÝ †nj&_ wKU (û, 2011) G cvIqv hvq L Zxeª †ÿ‡Î 1 MÖv ch©šÍ Riæwi n‡Z cv‡i| Mhw` GB DcmM©wU †`Lv hvq, Z‡e ZrÿYvr Gw›UmvB‡KvwUK †gwWwmb cÖ`vb eÜ Kiæb Ges e¨w³wU‡K kxZj cwi‡e‡k ivLyb I h‡_ó cvbxq mieivn Kiæb| †Uwej mvB 2: Gw›U‡Kvwjb‡RwiK †gwW‡Kkb ‡gwW‡Kkb evB‡cwi‡WbK UªvB‡n·‡dwbwWj ïiæi †WvR 1 wg.MÖv. cÖwZw`b y`Õevi 1 wg.MÖv. cÖwZw`b wUwcK¨vj Kvh©Kix †WvR 3–6 wg.MÖv./w`b( m‡e©v”P 12 wg.MÖv. †WvR) 5–15 wgMÖv cÖwZw`b (m‡ev©”P 20 wg.MÖv. †WvR) iæU Iivj Iivj wmMwbwd‡K›U mvBW B‡d±m: KbwdDkb, †ggwi wW÷v‡e©Ý (we‡kl K‡i eq¯‹‡`i gv‡S) +++ +++ wm‡Wmb (we‡kl K‡i eq¯‹‡`i gv‡S) + + BDwibvwi †nwR‡UwÝ ++ ++ K B›UviG‡RwÝ Bgv‡R©wÝ †nj&_ wKU (û, 2011) G cvIqv hvq L. g‡bvmvgvwRK wPwKrmv: me‡ÿ‡Î 1. mvB‡KvGWz‡Kkb w`b e¨w³wUi D‡Ï‡k¨ Ges †mev cÖ`vbKvixi D‡Ï‡k¨ ¸iæZ¡c~Y© evZ©v: » mvB‡Kvwmm wPwKrmv‡hvM¨ Ges AvµvšÍ e¨w³wU my ’¯ nq| » gvbwmK Pvc mvB‡KvwUK DcmM©¸‡jv evwo‡q †`q| » wbZ¨w`‡bi mvgvwRK, wkÿvMZ I †ckvMZ KvRKg© Pvwj‡q hvIqvi †Póv Kiæb, hw`I Riæwi Ae¯’vi g‡a¨ Zv Kiv KwVb| » A¨vj‡Kvnj, MvuRv ev Ab¨ civgk©wenxb Ilya wb‡eb bv, KviY G‡Z Ae¯’vi AviI AebwZ n‡Z cv‡i| » mvB‡Kvwm‡m AvµvšÍ e¨w³‡`i wbqwgZ †cÖmµvBe Kiv Il ya MÖnY Kiv DwPZ Ges wbqwgZ d‡jv AvcI Kiv DwPZ| » jÿ¨ ivLyb, mvB‡KvwUK DcmM©mg~n wdi‡Q wKbv wKsev AviI Lvivc n‡”Q wKbv| Ggb n‡j ZrÿYvr wPwKrmv‡K‡›`ª †hvMv‡hvM Kiæb, KviY e¨e¯’vcbv †mB wn‡m‡e cwieZ©b Ki‡Z n‡e| †meK‡`i cÖwZ evZ©v: » AvµvšÍ e¨w³‡K ‡Rvi K‡i GUv ¯^xKvi Kiv‡Z hv‡ebv bv †h, Zvi wek¦vm I AbywfwZ¸‡jv me wg_¨v, †KvbUvB ev¯Íe bq| » wbi‡cÿ I mnvqZvkxj nIqvi †Póv Kiæb, GgbwK hLb e¨w³wU A¯^vfvweK AvPiY Ki‡Q wKsev AvMÖvmx e¨envi Ki‡Q, †mB mg‡qI| » e¨w³wUi mv‡_ ZK© ev Zvi cÖwZ weiƒc AvPiY Kiv †_‡K weiZ _vKzb| » Zv‡K PjvPj Kivi c~Y© ¯^vaxbZv w`b| wbw`©ó MwЇZ AvU‡K ivL‡ebv bv †mB mv‡_ GUvI wbwðZ Kiæb †h Zvi wbivcËvq †hb †Kvb MvwdjwZ bv _v‡K| » mvB‡Kvwmm †Kvb hv`y-‡Uvbvi gva¨‡g nq bv| » mvB‡Kvwm‡mi Rb¨ †mB e¨w³wU‡K wKsev cwiev‡ii Ab¨ †Kvb m`m¨‡K †`vl w`‡eb bv| » hw` e¨w³wU B`vwbs Kv‡j †Kvb ev”Pvi Rb¥ w`‡q _v‡K, Z‡e ev”Pvi wbivcËvi Rb¨, ev”Pvi mv‡_ Zv‡K GKv ivL‡eb bv| 2. KwgDwbwU‡Z cybev©m‡b mnvqZv Kiæb » KwgDwbwU †bZv‡`i mv‡_ Avjvc Kiæb hv‡Z Gme e¨w³‡`i cÖwZ KwgwDwbwUi MÖnY‡hvM¨Zv I mnbkxjZv e„w× cvq| » A_©‰bwZK I mvgvwRK KvRK‡g© AskMÖn‡Yi my‡hvM K‡i w`b| » KwgDwbwUi cwi‡levmg~‡ni mv‡_ †hvMv‡hvM ¯’vcb Kwi‡q w`b †hgb, ¯^v¯’¨Kg©x, cÖ‡UKkb mvwf©m Kg©xiv, mgvRKg©xiv Ges wWRG¨vwewjwU mvwf©m Kg©x| e¨w³wUi h_vh_ mvgvwRK, wkÿvMZ I †ckvMZ Rxeb ïiæ Ki‡Z mnvqZv Kiæb| 3. wcÖwÝcvj Ad wiwWDwms †÷ªm GÛ †÷wš’s †mvk¨vj mv‡cvvU© (>> †Rbv‡ij wcÖwÝcvj Ad †Kqvi) Abyhvqx †meK‡`i †mev cÖ`vb Kiæb M. d‡jv-Avc » e¨e ’¯vcbv bxwZ (>> †mevi mvaviY g~jbxwZ) Abyhvqx wbqwgZ d‡jv-Avc †mk‡bi e¨e¯’v Kiæb| » DcmM©¸‡jv †_‡K m¤ú~Y© gyw³i c‡iI Kgc‡ÿ 12 gvm Gw›UmvB‡KvwUK Ilya Pvwj‡q hvb| m¤¢e n‡j GKRb we‡kl‡Ái mv‡_ mvÿvZ K‡i wm×všÍ wbb †h, Ilya Pvjy ivL‡eb bv eÜ K‡i †`‡eb| » wØZxq †mk‡bi Rb¨ 1 mßv‡ni g‡a¨ e¨e¯’v Kiæb Ges cieZ©x¸‡jv Ae¯’vi cwi‡cÖwÿ‡Z e¨e¯’v Kiæb| » Gw›UmvB‡KvwUK wPwKrmv eRvq ivLyb| m¤¢e n‡j GKRb we‡kl‡Ái mv‡_ mvÿvr K‡i wm×všÍ wbb †h, Ilya Pvjy ivL‡eb bvwK eÜ K‡i w`‡eb| P S Y 43 g„Mx‡ivM/wLuPzbx wb¤œ I ga¨ Av‡qi †`k¸‡jvi gvbweK cwiw¯’wZ‡Z gvbwmK, ¯œvq yweK I gv`K`ªe¨ e¨envi RwbZ (GgGbGm) mgm¨v¸‡jvi g‡a¨ me‡P‡q †ewk wPwKrmv †`qv mgm¨v n‡jv g„Mx‡ivM (Gwc‡jcwm)| g„Mx‡ivM Kg eqmx wkïmn me eq‡mB n‡q _v‡K| g„Mx‡ivM nj Ggb GK `xN©¯ ’vqx ¯œvqyweK Ae¯’v hv‡Z gw ͯ‡®‹i A¯^vfvweK B‡jw±ªK¨vj Kvh©µ‡gi Kvi‡Y cÖ‡ivPbv QvovB evi evi wLuPzbx nq| A‡bK ai‡bi g„Mx‡ivM Av‡Q Ges GB gwWD‡j †KejgvÎ me‡P‡q e¨vcK Kbfvjwmf Gwc‡jwá wb‡q Av‡jvPbv Kiv n‡q‡Q| Kbfvjwmf Gwc‡jwá n‡jv Ggb GK ai‡bi wLuPzbx, hv Awb”QvK…Z AvKw®§K ch©vqµwgK †cwk ms‡KvPb I wkw_jvqb, Gi d‡j kixi I A½cÖZ¨½¸‡jv Kuvc‡Z _v‡K A_ev k³ n‡q hvq| wLuPzbx cÖvq mgqB Ávb nviv‡bvi ˆeKj¨Zvi mv‡_ m¤úK©hy³| GKRb e¨w³ wLuPzbxi mgq c‡o †h‡Z cv‡ib Ges AvnZ n‡Z cv‡ib| Riæwi gvbweK cwiw¯’wZ‡Z Gw›UGwc‡jwÞK Ilya mieivn cÖvqB evavMÖ ’¯ nq| wbqwgZ Ilya cvIqv Qvov g„Mx †iv‡M AvµvšÍ e¨w³ cybivq wmRv‡ii wkKvi n‡Z cv‡ib, hv Rxe‡bi SzuwK n‡Z cv‡i| †Kvb e¨w³ wLuPzwb ev wmRv‡ii ci AÁvb n‡j Zvi A¨v‡mm‡g›U I e¨e¯’vcbvi Rb¨ 40 c„ôvq BwcAvB 2 e· †`Lyb|* EPI Kbfvjwmf Gwc‡jcwmi mvaviY Awf‡hvMmg~n  Kbfvjwmf gyf‡g›U ev wLuPzbxi BwZnvm| 45 A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1: Kbfvjwmf wmRv‡ii ˆewk󨸇jv wK e¨w³wU c~iY K‡i? » e¨w³ I Zvi hZœKvix‡K wR‡Ám Kiæb, wb‡Pi DcmM©¸‡jvi †KvbUv e¨w³i Av‡Q wK-bv: ◆ 1-2 wgwb‡Ui AwaK mgq a‡i wLuPzbx _v‡K ◆ †PZbv nvwi‡q hvIqv ev K‡g hvIqv ◆ kixi ev A½cÖZ¨½¸‡jv 1-2 wgwb‡Ui AwaK mgq k³ ev Abgbxq _vKv ◆ wRnŸvq Kvgo ev AvNvZ A_ev kvixwiKfv‡e AvnZ nIqv ◆ wLuPzbx PjvKv‡j cÖmve ev cvqLvbvi wbqš¿Y nvwi‡q †djv ◆ A¯^vfvweK bovPovi ci e¨w³wU wØavMÖ ’¯, Z`ªv”Qbœ, wSgv‡bv ev A¯^vfvweK AvPiY Ki‡Z cv‡ib| e¨w³wU Aemv`, gv_ve¨v_v ev †ckx e¨v_vi K_vI ej‡Z cv‡ib| » e¨w³ Kgcvjwmf wmRv‡ii ˆewkó¨ c~iY Ki‡e hw` Zvi Kgcvjwmf gyf‡g›U _v‡K Ges Dc‡ii ZvwjKvi Av‡iv AšÍZ `yÕwU jÿY _v‡K| » hw` Dc‡iv³ Dcm‡M©i g‡a¨ ïaygvÎ 1 ev 2wU †_‡K _v‡K, Z‡e G‡K bb-Kgcvjwmf wmRvi ev Ab¨ †Kvb †ivM e‡j aviYv Kiæb| ◆ e¨w³i hw` G‡Ki AwaK bb-Kgcvjwmf wmRv‡ii jÿY _v‡K, Z‡e we‡kl‡Ái civgk© wbb| ◆ hw` Ab¨ †Kvb †ivM †_‡K _v‡K, Z‡e †m Abyhvqx e¨e ’¯v wbb| ◆ cybivq g~j¨vqb Ki‡Z 3 gvm ci d‡jv Avc Kiæb| A¨v‡mm‡g›U cÖkœ 2: Kbfvjwmf wmRvi n‡q _vK‡j, Gi wK AvKw®§K †Kvb KviY Av‡Q? » wbD‡ivBb‡dKkb/ œ¯vqycÖ` v‡ni jÿY I DcmM©¸‡jv hvPvB Kiæb: ◆ R¡i ◆ gv_ve¨v_v ◆ †gwbbwRqvj Bwi‡Ukb/R¡vjv‡cvov* (†hgb, k³ Nvo)| » wLuPzbxi Ab¨vb¨ m¤¢ve¨ KviY hvPvB Kiæb: ◆ gv_vq AvNvZ ◆ †gUvewjK/cwicvKxq A¯^vfvweKZv* (†hgb, nvB‡cvMøvB‡Kwgqv*, nvB‡cv‡bwUªwgqv*) ◆ A¨vj‡Kvnj ev gv`‡Ki welwµqv ev DB_WªIqvj (>> 48 c„ôvq Aew¯’Z GmBDwe 1 e·)| » hw` Kbfvjwmf wmRv‡ii wPwýZ Kivi g‡Zv †Kvb AvKw®§K KviY cvIqv hvq, Z‡e IB Kvi‡Yi wPwKrmv Kiæb| ◆ Gme †ÿ‡Î Gw›UGwc‡jwÞK Ilya w`‡q wPwKrmv †`Iqv Riæwi bq| » hw` wbD‡ivBb‡dKk/ ø¯vqycÖ` vn* nq, gv_vq AvNvZ ev †gUvewjK A¨vebigvwjwU aiv c‡i, Z‡e ZrÿYvr nvmcvZv‡j cvVvb| ◆ wkïi (6 gvm †_‡K 6 eQi) †ÿ‡Î hw` R¡imn wb‡Pi Kg‡cø· wdeªvBj wmRv‡ii †h‡Kvb GKwU DcmM© Dcw¯’Z _v‡K, Z‡e ¯œvqycÖ` vn m‡›`n Kiæb: ▸ †dvKvj wmRvi – kix‡ii †h‡Kvb GKwU As‡k wLuPzbx ïiæ nq ▸ †cÖvj½W (`xN©vwqZ) wmRvi – 15 wgwb‡Ui †ewk wLuPzbx _vK‡j ▸ wiwc‡UwUf wmRvi – eZ©gvb Amy¯’Zvi mg‡q GKvwaK wLuPzbx n‡j ◆ hw` R¡‡i AvµvšÍ wkïi gv‡S Dc‡ii 3Uv Dcm‡M©i GKwUI bv _v‡K, Z‡e mvaviY wdeªvBj wLuPzbx aviYv Kiæb| R¡‡ii e¨e ’¯v wbb Ges ’¯vbxq AvBGgwmAvB Abyhvqx Gi KviY LyuRyb| wkïwU‡K 24 N›Uv ch©‡eÿY Kiæb| » cybivq g~j¨vqb Ki‡Z 3 gvm ci d‡jvAvc Kiæb| A¨v‡mm‡g›U cÖkœ 3: hw` Kbfvjwmf wmRv‡ii †Kvb AvKw®§K KviY Lyu‡R cvIqv bv hvq, Zvn‡j GUv wK g„Mx‡ivM? » GwU g„Mx‡ivM we‡ewPZ n‡e, hw` e¨w³wU MZ 12 gv‡m c„_K 2 w`‡b 2 ev Z‡ZvwaK evi †Kvb KviY Qvov Kbfvjwmf wmRv‡i AvµvšÍ nq| » hw` AvKw®§K †Kvb KviY Qvov MZ 12 gv‡m gvÎ GKevi Kbfvjwmf wmRvi nq, Z‡e Gw›UGwc‡jwÞK wPwKrmvi cÖ‡qvRb †bB| 3 gv‡mi g‡a¨ d‡jvAvc Kiæb| g~j wPwKrmv cwiKíbv 1. g„Mx‡ivM m¤ú‡K© AvµvšÍ e¨w³ I Zvi †mev`vbKvix‡K Ávb w`b » e¨vL¨v Kiæb: ◆ g„Mx‡ivM wK Ges GUv †Kb nq: ▸ g„Mx‡ivM GKwU `xN©‡gqv`x Ae ’¯v, wKš‘ wPwKrmvq cÖwZ PviR‡bi wZbRb wLuPzbxgy³ _vK‡Z cv‡ib| ▸ g„Mx‡iv‡M wLuPzbx evievi N‡U| wLuPzbx n‡jv gw ͯ‡®‹i A¯^vfvweK B‡jw±ªKvj Kvh©µg m¤úK©xZ mgm¨v| ▸ hv y`‡Uvbv ev Ava¨vwZ¥K Kvi‡Y g„Mx‡ivM nq bv| ▸ g„Mx‡ivM †Quvqv‡P bq| jvjvi gva¨‡g G †ivM Qovq bv| ◆ cÖvmw½K Rxebhvc‡bi welq¸‡jv wK wK? ▸ g„Mx †iv‡M AvµvšÍ e¨w³ ¯^vfvweK Rxeb hvcb Ki‡Z cv‡ib ∙ Zviv we‡q Ki‡Z cv‡ib Ges my¯’ mšÍvb Rb¥ w`‡Z cv‡i| ∙ AwaKvsk PvKwiB Zviv djcÖmyfv‡e wbivc‡` Ki‡Z cv‡ib| ∙ g„Mx‡iv‡M AvµvšÍ wkïiv ¯‹z‡j †h‡Z cv‡i| ▸ g„Mx †iv‡M AvµvšÍ e¨w³‡`i Gov‡bv DwPZt ∙ †hme PvKwi‡Z fvix hš¿cvwZ ev Av¸b Kv‡Q KvR Ki‡Z nq ∙ Db¥y³ Av¸‡b ivbœvevbœv Kiv ∙ GKvKx muvZvi KvUv ∙ A¨vj‡Kvnj ev we‡bv`bg~jK gv`K MÖnY ∙ R¡vjv‡bv evwZi w`‡K ZvwK‡q _vKv ∙ wb ª`vi wbqg cwieZ©b Kiv (†hgb, ¯^vfvwe‡Ki †P‡q Kg Nygv‡bv)| ◆ wLuPzbx n‡j, N‡i wK Ki‡Z n‡e (†mev`vbKvix cÖwZ wb‡`©kbv)t ▸ hw` `vuov‡bv ev emv Ae ’¯vq wLuPzbx ïiæ nq, Z‡e Zv‡K c‡o wM‡q AvnZ nIqv †_‡K iÿv Kiæb, e¨w³‡K gvwU‡Z em‡Z ev ï‡q co‡Z mvnvh¨ Kiæb| ▸ wbwðZ Kiæb †h e¨w³wU h_vh_fv‡e k¦vm wb‡Z cvi‡Q| Nv‡oi Pvicv‡ki †cvkvK wXjv K‡i w`b| ▸ e¨w³‡K wiKfvwi Ae¯’v‡b ivLyb (K-N Qwe ª`óe¨)| wPÎ K-N: wiKfvwi Ae¯’vb K L M N K. e¨w³i GKcv‡k nuvUz †Mu‡o emyb| e¨w³i †h nvZ Avcbvi me‡P‡q Kv‡Q †mUv‡K mg‡Kv‡Y evuKv K‡i e¨w³wUi gv_vi Dci w`‡K Zzjyb (K wP‡Î †`‡L wbb)| L. e¨w³i Aci nvZ Zvi gv_vi wb‡P Ggbfv‡e ivLyb, hv‡Z nv‡Zi †cQb cvkUv e¨w³i Mvj ¯úk© K‡i (L wP‡Î †`‡L wbb)| M. Avcbvi †_‡K †h nvuUzwU `~‡i Av‡Q †mUv‡K mg‡Kv‡Y evuKv K‡i w`b| mveavbZvi mv‡_ fvR Kiv nvuUzwU †U‡b e¨w³wU‡K Nywi‡q w`b (M wP‡Î †`‡L wbb)| N. e¨w³wUi Dc‡ii nvZUv gv_v‡K †VwK‡q ivL‡e Ges wØZxq nvZUv †hb AwZwiw³ †eu‡K bv hvq, †mUv wbwðZ Ki‡e (wPÎ N †_‡K †`‡L wbb)| kZK©Zvi mv‡_ e¨w³i gv_vwU wcQ‡bi w`‡K nvjKv †V‡j gv_vwU Dc‡ii DwV‡q hvPvB K‡i wbb, †hb †Kvb wKQz k¦vm-cÖk¦v‡m evuav m„wó bv K‡i| GUv Zvi wRnŸv‡K k¦vm-cÖk¦v‡mi iv¯Ív †_‡K `~‡i ivL‡e Ges e¨w³wU‡K fv‡jvfv‡e k¦vm wb‡Z mvnvh¨ Ki‡e Ges jvjv ev ewg n‡j `g AvUKv‡bv cÖwZ‡iva Ki‡e| ▸ e¨w³‡K †eu‡a ivL‡eb bv ev †g‡S‡Z AvU‡K ivL‡eb bv| ▸ e¨w³i gy‡L †Kvb wKQz XzKv‡eb bv| ▸ kvixwiK AvNvZ †_‡K evuPv‡Z e¨w³i Avkcvk †_‡K k³ I aviv‡jv wRwbm mwi‡q ivLyb| ▸ hZÿY bv wLuPzwb _v‡g Ges e¨w³i †PZbv †d‡i, ZZÿY Zvi mv‡_ _vKzb| » Ask e¨w³wU‡K Ges Zvi †meK‡`i‡K ejyb GKwU †QvÆ wLuPzbxi Wv‡qwi mv‡_ ivL‡Z (BwcAvB wRwcwm 1 wPÎ †`Lyb)| 47 2. Gw›U-Gwc‡jwÞK Jlya ïiæ Kiæb ev cybivq ïiæ Kiæb: » wLuPzbx wbqš¿Y K‡i Ggb Gw›U-GwcwjwÞK Jlya e¨w³wU KLbI e¨envi K‡i‡Q wK-bv Zv hvPvB Kiæb| hw` nu¨v nq, cybivq GKB Jlya GKB gvÎvq ïiæ Kiæb| » hw` †mB Jlya cvIqv bv hvq, Z‡e bZzb Jlya ïiæ Kiæb| » †Kej GKwU Gw›U-GwcwjwÞK Jlya †e‡Q wbb (†`Lyb †Uwej BwcAvB 1)  m¤¢ve¨ cvk¦© cÖwZwµqv, Jlya-†ivM wg_w®Œqv* wKsev Jlya- Jlya wg_w®Œqv* we‡ePbvq wbb| cÖ‡qvR‡b RvZxq ev WvweøDGBPIÕi Ilya cÖ¯ ‘ZKvixi civgk© wbb|  wLuPzbx wbqš¿‡Y bv Avmv ch©šÍ ¯^íZg gvÎv w`‡q Ilya ïiæ Kiæb Ges ax‡i ax‡i gvÎv evovb| » e¨w³‡K I hZœKvix‡K e¨vL¨v Kiæb:  Jly‡ai gvÎv I mgq (>> †Uwej BwcAvB 1)  m¤¢ve¨ cvk¦© cÖwZwµqv (>> †Uwej BwcAvB 1) AwaKvsk cvk¦© cÖwZwµqv g„`y Ges mg‡qi mv‡_ Zv K‡g hvq| gvivZ¥K cvk¦© cÖwZwµqv †`Lv w`‡j mv‡_ mv‡_B Jlya eÜ w`‡Z n‡e Ges †gwW‡Kj mvnvh¨ wb‡Z n‡e|  Jlya Pvwj‡q hvIqvi ¸iæZ¡| †Kvb †WvR ev` co‡j ev AvKw®§K Ilya eÜ K‡i w`‡j wLuPzbx cybivq wd‡i Avm‡Z cv‡i| cÖwZw`b GKB mg‡q Jlya wb‡Z n‡e|  Jly‡ai KvR ïiæi Kivi mgq| Ily‡ai cÖfve cwi®‹vi eyS‡Z mvaviYZ K‡qK mßvn jv‡M|  wPwKrmvi mgqmxgv| wLuPzbx bv n‡j Kgc‡¶ y`ÕeQi Jlya Pvwj‡q †h‡Z n‡e|  wbqwgZ d‡jv-Avc cÖ‡qvRb| †Uwej BwcAvB 1: Gw›U-Gwc‡jwÞK Ilyamg~n a Available in the Interagency Emergency Health Kit (WHO, 2011) †d‡bveviweUvj* Kvievgv‡Rwcb †dwbU‡qb fvj‡cÖv‡qU wkï‡`i cÖ_g †WvR 2-3 GgwR/†KwR/w`b 5 GgwR/†KwR/w`b 3-4 GgwR/†KwR/w`b 15-20 GgwR/†KwR/w`b wkï‡`i ˆewkó¨m~PK Kvh©Ki †WvR 2-6 GgwR/†KwR/w`b 10-30 GgwR/†KwR/w`b 3-8 GgwR/†KwR/w`b (m‡e©v”P †WvR 300 GgwR/w`b) 15-30 GgwR/†KwR/w`b cÖvßeq¯‹‡`i cÖ_g †WvR 60 GgwR/w`b 200-400 GgwR/w`b 150-200 GgwR/w`b 400 GgwR/w`b cÖvßeq¯‹‡`i ˆewkó¨m~PK Kvh©Ki †WvR 60-180 GgwR/w`b 400-1400 GgwR/w`b 200-400 GgwR/w`b 400-2000 GgwR/w`b †Wv‡Ri mgqm~wP w`‡b GKevi Nygv‡bvi mgq w`‡b y`Õevi wkï‡`i w`‡b y`Õevi, eo‡`i w`‡b GKevi †`qv †h‡Z cv‡i mvaviYZ w`‡b 2 ev 3 evi weij, wKš‘ ¸iæZi cvk¦©-cÖwZwµqv * Pvgovq ¸iæZi dzmKzwo (w÷‡fÝ-Rbmb wmb‡Wªvg*) * †evb g¨v‡iv wW‡cÖkb/Gi Kg©ÿgZv K‡g hvIqv* * wjfvi bó * Pvgovq ¸iæZi dzmKzwo (w÷‡fÝ-Rbmb wmb‡Wªvg*, welv³ GwcWvigvj †b‡µvjvBwmm*) * †evb g¨v‡iv welYœZv* * Gwbwgqv I Ab¨vb¨ †ngv‡UvjwRK¨vj A¨vebigvwjwUwR * Pvgovq ¸iæZi dzmKzwomn (w÷‡fÝ-Rbmb wmb‡Wªvg*) nvBcvi‡mbwmwfwU wiA¨vKkbm * †ncvUvBwUm * Z›`ªv”QbœZv * wØav mvaviY cvk¦©-cÖwZwµqv * Z›`ªv”QbœZv * wkï‡`i g‡a¨ nvBcviA¨vKwUwfwU * Z›`ªv”PbœZv * nuvU‡Z Amyweav * kixi ¸jv‡bv * kixi ¸jv‡bv, ewg, †KvôKvwVb¨ * Kuvcywb * Z›`ªv”QbœZv * A¨vUvw·qv I A¯úó K_v * †ckx ¯ú›`b * gvbwmK wØav * RoZv/Aemv`MÖ¯’Zv * wb‡¯ÍR * Kuvcywb * kixi ¸jv‡bv, Wv‡qwiqv * IRb e„w× * ÿY ’¯vqx Pzjcov (mvaviYZ 6 gv‡mi g‡a¨ cybivq R‡b¥) * wjfv‡ii Kvh©KvwiZvq ˆeKj¨ mveavbZv * eyw× cÖwZeÜx I AvPiYMZ mgm¨v _vK‡j wkï‡`i †d‡bveviweUvj w`‡eb bv * Mf©eZx bvix‡`i f¨vj‡cv‡iU w`‡eb bv 3. d‡jvAvc: » cÖwZwbqZ d‡jv-Avc wbwðZ Kiæb:  cÖ_g wZbgvm ev wLuPzbx wbqš¿‡Y bv Avmv ch©šÍ gv‡m AšÍZ GKevi d‡jvAvc A¨vc‡q›U‡g‡›Ui mgqm~wP wVK Kiæb|  wLuPzbx wbqš¿‡Y Avm‡j 3 gv‡m GKevi †`Lv Kiæb|  d‡jvAv‡ci we ͯvwiZ civg‡k©i wel‡q Rvb‡Z e¨e¯’vcbvi g~jbxwZ †`Lyb (>> †mevi mvaviY g~jbxwZ) » cÖwZwU d‡jvAv‡c:  wLuPzbx wbqš¿Y ch©‡e¶Y: ▸ wLuPzbx KZ fvjfv‡e wbqš¿‡Y Avm‡Q, Zv †`L‡Z wLuPzbx Wv‡qwi ivL‡Z ejyb|  wLuPzbx KZ fvjfv‡e wbqš¿‡Y Avm‡Q, Zvi wfwˇZ Gw›UGwc‡jwÞK Ily‡ai gvÎv wVK ivLyb ev mgš^q Kiæb| ▸ hw` GKwU Ily‡ai m‡e©v”P †_ivwcDwUK †Wv‡Ri e¨envi wKsev Jly‡ai cvk¦©-cÖwZwµqv Amnbxq nq, Z‡e Ilya cwieZ©b Kiæb| wLuPzbx wbqš¿‡Y bv Avmv ch©šÍ µgvš^‡q Ily‡ai gvÎv evovb| ▸ hw` wLuPzbx LyeB Kg nq Ges Jly‡ai gvÎv evov‡bvi d‡j cvk¦©-cÖwZwµqv ¸iæZi nIqvi m¤¢vebv _v‡K, Z‡e eZ©gvb gvÎvwUB MÖnY‡hvM¨ n‡Z cv‡i| ▸ hw` 2wU Jlya GKwUi ci Av‡iKwU †`qv nq wKsev †KvbwUB wLuPzbx wbqš¿‡Y h‡_ó bv nq, Z‡e we‡klÁi civgk© wbb| GKmv‡_ y`ÕwU Gw›UGwc‡jwÞK Jlya cÖ‡qvM Gwo‡q Pjyb|  hw` y`B eQ‡ii g‡a¨ †Kvb wLuPzbx bv nq, Z‡e Gw›UGwc‡jwÞK Jlya eÜ K‡i w`‡Z cv‡ib| ▸ Jlya e‡Üi d‡j Avev‡iv wLuPzbx hv‡Z bv nq, †mRb¨ Ilya e‡Üi Av‡M K‡qK gvm Av‡M †_‡K Gi gvÎv ax‡i ax‡i Kgv‡Z n‡e|  wLuPzbx wbqš¿Y n‡”Q wK-bv, Zv ch©‡e¶‡Y hZœKvix‡K Kv‡R jvMvb|  Rxeb-hvcb c×wZ ch©v‡jvPbv Kiæb Ges Avev‡iv mvB‡Kv GWy‡Kkb w`b / e¨w³ I hZœKvix‡K mnvqZv w`b (>> †gŠwjK e¨e ’¯vcbv cwiKíbv avc 1 Dc‡i eY©bv Kiv n‡q‡Q)| e· BwcAvB 1: g„Mx‡iv‡M Avµvš— bvix‡`i †¶‡Î we‡kl e¨e ’¯vcbv » bvix hw` Mf©aviY eqmx n‡q _v‡Kb:  Mf©ve ’¯vq ÎæwU †iv‡a 5 wg.MÖv./w`‡b †dv‡jU w`b| » hw` wZwb Mf©eZx nb:  e¨e ’¯vcbvi Rb¨ we‡kl‡Ái civgk© wbb|  mšÍvb R‡b¥i Av‡M evievi †PKAvc Kiv Ges nvmcvZv‡j †Wwjfvwii civgk© w`b|  cÖm‡ei mgq, beRvZ‡Ki †ckx‡Z 1 wg.MÖv. wfUvwgb †K w`b| » Gw›UGwc‡jwÞK Ilya ïiæi wm×všÍ Mf©avwiYxi mv‡_ Av‡jvPbvi K‡iB wb‡Z n‡e| wLuPzbxi gvÎv I cybive„wË Ges †mB mv‡_ wLuPzbx ev Ilya †_‡K åæ‡Yi m¤¢ve¨ ¶wZ we‡ePbv Ki‡Z n‡e| hw` Ilya ïiæi wm×všÍ nq, Z‡e †d‡bveviweUvj A_ev Kve©vgv‡Rwcb w`‡Z cv‡ib| fvj‡cv‡iU Ges cwj‡_ivcx Govb| » ¯Íb¨cv‡bi mgqKv‡j Kve©vgv‡Rwcb e¨envi Kiv †h‡Z cv‡i| bKkv BwcAvB 1: wLuPzbx Wv‡qwii D`vniY: KLb wLuPzbx n‡q‡Q wLuPzbxi eY©bv (kix‡ii cÖfvweZ Ask Ges wLuPzbxi †gqv`) †h Ilya †bqv n‡q‡Q ZvwiL mgq MZKvj AvR 49 e· BwcAvB 2: e¨w³i A¨v‡mm‡g›U I e¨e ’¯vcbv, hvi wmRv‡ii ci wLuPzwb nq A_ev Ávb nvivq AvKw®§K wLuPzbxi A¨v‡mm‡g›U I e¨e ’¯vcbv Pvjv‡Z n‡e GKB mg‡q| » wmRv‡ii A¨v‡mm‡g›U  axi-w¯’i _vKzb| †ewki fvM wLuPzbx K‡qK wgwb‡Ui g‡a¨B †kl nq|  k¦vmbvjx, k¦vm-cÖk¦vm I i³ mÂvjb cix¶v Kiæb, i³Pvc, k¦vm hš¿ I ZvcgvÎvmn|  gv_v ev †giæ`‡Ð AvNv‡Zi wPý cix¶v Kiæb (†hgb- †Pv‡Li cÖmvwiZ gwb gv_vq ¸iæZi AvNv‡Zi wPý n‡Z cv‡i)|  k³ Nvo ev R¡i cix¶v Kiæb (†gwbbRvBwU‡mi j¶Y) » hZœKvix‡K wRÁvmv Kiæb:  KLb wLuPzbx ïiæ n‡qwQj?  wLuPzbxi c~e© BwZnvm Av‡Q wK?  gv_v wKsev Nv‡oi AvNv‡Zi †Kvb NUbv Av‡Q?  Ab¨ †Kvb kvixwiK mgm¨v Av‡Q wK?  e¨w³wU wK †Kvb ai‡bi Jlya, wel, g` ev gv`K wb‡qwQ‡jb?  hw` bvix n‡q _v‡Kb, GUv wK Zuvi Mf©avi‡Yi wØZxqva© ev cÖm‡ei cÖ_g mßvn? » RiæwiwfwˇZ nvmcvZv‡j cvVvb:  hw` eo ai‡bi AvNvZ, †PvU ev k¦vm-cÖk¦v‡mi mgm¨vi j¶Y _v‡K  hw` e¨w³i gv_v ev Nv‡o ¸iæZi AvNvZ †_‡K _v‡K ▸ e¨w³ Nvo bvov‡Z cvi‡Qb bv| ▸ Zv‡`i ’¯vbvšÍ‡ii mgq e¨w³i †giæ`Ð †mvRv K‡i wb‡q hvIqv| ▸ e¨w³ hw` bvix n‡q _v‡Kb, whwb Mf©avi‡Yi wØZxqv‡a© ev cÖm‡ei cÖ_g mßvq Av‡Qb| ▸ hw` ø¯vqy msµgY m‡›`n nq| ▸ wLuPzbx ïiæi ci 5 wgwb‡UiI †ewk n‡q †M‡j| » wLuPzbx e¨e ’¯vcbv  †ivMx‡K GKcvk K‡i wiKfvwi Ae¯’vq ivLyb (Dc‡ii †gŠwjK e¨e ’¯vcbv cwiKíbv I K-N Qwe †`Lyb)  hw` 1-2 wgwb‡Ui g‡a¨ wLuPzbx wb‡R †_‡KB eÜ bv nq, Z‡e hZ ª`æZ m¤¢e wkivq (AvBwf) Møy‡KvR I †eb‡RvWvqv‡Rwcb w`b ax‡i ax‡i (30 †dvuUv/wgwbU) w`b| ▸ hw` wkivq †`Iqv KwVb nq, Z‡e gjØv‡i †eb‡RvWvqv‡Rwcb w`b| ▸ mveavbZv: †eb‡RvWvqv‡Rwcb k¦vm-cÖk¦vm axi Ki‡Z cv‡i| Aw·‡Rb _vK‡j w`b Ges evievi e¨w³i k¦vm- cÖk¦v‡mi Ae ’¯v cixÿv Kiæb| ▸ wkïi †¶‡Î Møy‡Kv‡Ri gvÎv: 50% Møy‡Kv‡Ri 2-5 wg.wj./†KwR| ▸ wkïi †¶‡Î †eb‡RvWvqv‡Rwc‡bi gvÎv: ∙ gjØv‡i WvqvwRcvg 0.2-0.5 wg.MÖv./†KwR ev ∙ WvqvwRcvg AvBwf 0.1-0.3 wg.MÖv./†KwR ev ∙ †jvivwRcvg 0.1 wg.MÖv./†KwR| ▸ cÖvß-eq¯‹‡`i Møy‡Kv‡Ri gvÎv: 50% Møy‡Kv‡Ri 5 wg.wj.| ▸ cÖvß-eq¯‹‡`i †eb‡RvWvqv‡Rwc‡bi gvÎv: ∙ WvqvwRcvg 10-20 wg.MÖv. ev ∙ WvqvwRcvg AvBwf 10-20 wg.MÖv. ax‡i ev ∙ †jvivwRcvg AvBwf 4 wg.MÖv. ▸ †eb‡RvWvqv‡Rwcb †ckx‡Z (AvBGg) w`‡eb bv|  †eb‡RvWvqv‡Rwc‡bi cÖ_g †WvR †`qvi ciI hw` 5-10 wgwbU wLuPzbx Ae¨vnZ _v‡K, Z‡e †eb‡RvWvqv‡Rwc‡bi wØZxq †WvR w`b|  cÖ_g gvÎvi g‡ZvB GKB †WvR w`b|  y`B †Wv‡Ri †ewk †eb‡RvWvqv‡Rwcb †`Iqv hv‡e bv| hw` `yB gvÎvi †ewk cÖ‡qvRb nq, Z‡e Zv‡K nvmcvZv‡j cvVv‡Z n‡e|  ÷¨vUvm Gwc‡jcwUKvm m‡›`n Kiæb, hw`: ▸ wLuPzbx evievi nq Ges Gwc‡mv‡Wi g‡a¨ wd‡i bv Av‡m, ev ▸ †eb‡RvWvqv‡Rwcb y`Õevi †`Iqvi ciI hw` mvov bv †g‡j, wKsev ▸ hw` wLuPzbx 5 wgwb‡Ui †ewk mgq a‡i _v‡K| » RiæwiwfwˇZ nvmvcvZv‡j cvVv‡eb:  hw` ÷¨vUvm Gwc‡jcwUKvm g‡b nq (Dc‡i †`Lyb)  †eb‡RvWvqv‡Rwcb y`Õevi †`Iqvi ciI e¨w³ hw` mvov bv †`q  †eb‡RvWvqv‡Rwcb †`Iqvi ci hw` e¨w³i k¦vm-cÖk¦v‡m mgm¨v †`Lv †`q| 40 51 eyw× cÖwZeÜx ID eyw× cÖwZewÜZv9 n‡jv cÖZ¨vwkZ eyw×e„wËK weKv‡ki wewfbœ †ÿÎRy‡o mxgve×Zv (†hgb, wePvi-eyw×* (KMwbwUf), fvlv, †ckx mÂvjb I mvgvwRK `¶Zv), hv cwieZ©b‡hvM¨ bv| GB mxgve×Zv Rb¥ †_‡K we`¨gvb A_ev wkïKv‡jB ïiæ| eyw× cÖwZewÜZvi Kvi‡Y wk¶v, cÖvZ¨wnK Kg©KvÐ Ges bZzb cwi‡ek gvwb‡q †bqvi †ÿ‡Î weNœ m„wó K‡i| eyw× cÖwZeÜx e¨w³i †ÿ‡Î cÖvqB A‡bK h‡Zœi cÖ‡qvRb nq| Zviv cÖvqB ¯^v¯’¨ †mev I wk¶v AR©‡b P¨v‡j‡Äi gy‡L c‡ob| wbh©vZb I Ae‡njvi †ÿ‡Î Zviv Pig AiwÿZ Ges wek„•Lj I SzuwKc~Y© Riæwi cwiw ’¯wZi m¤§yLxb nq| D`vniY¯^iƒc, eyw× cÖwZeÜx gvbyl A‡bK mgq bv ey‡SB wec`RbK ¯’v‡b P‡j hvq| GQvov cwievi I KwgDwbwU Zv‡`i †evSv e‡j Dcjwä Ki‡Z cv‡i Ges ¯’vbvšÍ‡ii mgq Zviv cwiZ¨³ n‡Z cv‡i| G Kvi‡Y Riæwi gvbweK cwiw ’¯wZ‡Z eyw× cÖwZeÜx e¨w³‡`i w`‡K AwZwi³ †Lqvj ivLv cÖ‡qvRb| GB gwWD‡j wkï, eqtmwÜ Ges cÖvßeq¯‹‡`i g‡a¨ gvSvwi, Zxeª I cÖMvp eyw× cÖwZewÜZv wb‡q Av‡jvPbv Kiv n‡q‡Q| Dc ’¯vwcZ Awf‡hvMmg~‡ni bgybv » beRvZ‡Ki †ÿ‡Î: ~`e©j Lv`¨ MÖnY, ¯^v¯’¨ evb bv nIqv, `ye©j †ckx-mÂvjb, Dchy³ eqm I avc Abyhvqx weKv‡ki cÖZ¨vwkZ gvBjdjK ¯úk© Ki‡Z †`wi nIqv, †hgb- nvmv, emv, `uvov‡bv| » wkï‡`i †ÿ‡Î: Dchy³ eqm I avc Abyhvqx weKv‡ki cÖZ¨vwkZ gvBjdjK ¯úk© Ki‡Z †`wi nIqv, †hgb- nuvUv, Uq‡jU cÖwkÿY, K_v ejv I cov‡jLv| » cÖvßeqK‡`i †¶‡Î: ¯^vaxbfv‡e Pjv A_ev wb‡Ri hZœ ev wkïi †`Lvïbv Kivi m¶gZv K‡g hvIqv| » me eq‡mi †¶‡Î: e¨w³i eqm Abyhvqx ¯^vfvweK we‡ewPZ ˆ`bw›`b KvRKg© Ki‡Z mgm¨v nIqv; wb‡ ©`kbv eyS‡Z mgm¨v nIqv, ˆ`bw›`b Rxe‡bi Pvwn`v gvb‡Z mgm¨v nIqv| 9 The draft, proposed ICD-11 name for this condition is Disorder of Intellectual Development. ৪১ A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1: e¨w³i wK eyw× cÖwZewÜZv Av‡Q? » e¨w³i `¶Zv I Kvh©KvwiZv hvPvB Kiæb:  †QvU wkï I beRvZ‡Ki †¶‡Î Zviv Zv‡`i eqm Dc‡hvMx gvBjdjK ¯úk© Ki‡Q wK-bv Zv hvPvB Kiæb| (mZK© wPýmn e· AvBwW 1)|  wkïi hZœKvixi Rb¨ cÖ¯ÍvweZ wKQz cÖkœ: ▸ Avcbvi wkï wK mgeqmx Ab¨vb¨‡`i gZ AvPiY Ki‡Q? ▸ Avcbvi wkï wb‡R wb‡R †Kvb ai‡bi KvR¸‡jv Ki‡Z cvi‡Q (emv, nvuUv, LvIqv, †cvlvK civ ev Uq‡jU Kiv)? ▸ wkï wKfv‡e Avcbvi mv‡_ fv‡ei Av`vb-cÖ`vb K‡i? wkï wK Avcbv‡K †`‡L nv‡m? wkï wK Zvi bvg ï‡b mvov †`q? †m wKfv‡e Avcbvi mv‡_ K_v e‡j? †m hv Pvq Zv wK Avcbv‡K ej‡Z cv‡i? ▸ Avcbvi wkï wKfv‡e †L‡j? Avcbvi wkï wK Zvi mgeqmx Ab¨vb¨ wkï‡`i mv‡_ fv‡jvfv‡e †Lj‡Z cv‡i?  AMÖR wkï I eqtmÜx‡`i †¶‡Î Zv‡`i wR‡Ám Kiæb, Zviv ¯‹z‡j hvq wKbv, hw` hvq, Z‡e wKfv‡e Zviv ¯‹z‡ji KvR K‡i (†kLv, cov, †jLv) Ges cÖwZw`b evwoi KvR| ▸ Zzwg wK ¯‹z‡j hvI? ¯‹zj †Kgb Pj‡Q? Zzwg ¯‹z‡ji KvR wK †kl Ki‡Z cv‡iv? wb‡`©kbv eyS‡Z I AbymiY Ki‡Z bv cvivi Kvi‡Y †Zvgvi wK ¯‹z‡j †Kvb mgm¨v nq?  eo‡`i †¶‡Î, Zv‡`i Kv‡R mgm¨v nq wK-bv wR‡Ám Kiæb, hw` ZvB nq, Z‡e wKfv‡e Zv‡`i KvR I Ab¨vb¨ ˆ`bw›`b KvR Ki‡Q? ▸ Avcwb wK KvR K‡ib? wK ai‡bi KvR K‡ib? wb‡ ©`kbv eyS‡Z ev AbymiY Ki‡Z mgm¨v nIqvi Kvi‡Y Avcwb KvR Ki‡Z mgm¨vq c‡ob?  AMÖR wkï, eqtmÜx I cÖvß-eq¯‹‡`i †ÿ‡Î Zv‡`i Kv‡Q Rvb‡Z Pvb †h, Zv‡`i cÖvZ¨wnK KvR Kivi Rb¨ KZUzKz mvnvh¨ Zviv †c‡q _v‡K (†hgb, evwo, ¯‹zj, PvKwi‡Z) » hw` Zv‡`i weKv‡ki gvBjdjK ¯úk© Ki‡Z †`wi nq, Z‡e wPwKrmv‡hvM¨ ev cwieZ©b‡hvM¨ Ae¯’vi K_v ev` w`b, hv eyw× cÖwZewÜZvi Abyiƒc n‡Z cv‡i|  „`wónxb n‡j ev` w`b: ▸ 6 gv‡mi †ewk wkïi †¶‡Î, hZœKvix‡K wRÁvmv Kiæb wb‡Pi¸wj wkïwU Ki‡Z cv‡i wK-bv, hLb wZwb wb‡R mivmwi ch©‡eÿY K‡i‡Qb: ∙ wkïwU †Kvb Pjgvb e ‘¯ †`‡L Zvi wcQz wb‡Z cv‡i wK-bv? ∙ wkïwU cwiwPZ gvbyl wPb‡Z cv‡i? ∙ wkïwU nvZ w`‡q †Kvb wKQz ai‡Z cv‡i wK-bv? ▸ hw` Gme cÖ‡kœi †KvbwUi DËi ÒbvÓ nq, Z‡e hZœKvix‡Ki Rvbvb †h, wkï „`wónxb n‡Z cv‡i Ges m¤¢e n‡j we‡kl‡Ái civgk© wbb|  kªeYnxb n‡j ev` w`b: ▸ 6 gv‡mi †ewk eqmx wkïi †¶‡Î hZœKvix‡K wR‡Ám Kiæb †h, wZwb hLb wkïwU‡K mivmwi ch©‡eÿY K‡i‡Qb, ZLb †m wb‡Pi KvR¸wj Ki‡Z †`‡L‡Qb wK-bv? ∙ †cQ‡b †K K_v ej‡Q, Zv †`Lvi Rb¨ wkïwU Nvo †Nvivq wK-bv? ∙ †Rv‡i kã n‡j wkïwU cÖwZwµqv †`Lvq wK-bv? ∙ wkïwU gyL w`‡q wewfbœ ai‡bi kã K‡i wK-bv (UvUv, WvWv, evev)? ▸ hw` Gme cÖ‡kœi DËi nq ÒbvÓ nq, Z‡e hZœKvix‡K Rvbvb †h, wkïwUi kÖeY ˆeKj¨ _vK‡Z cv‡i Ges hw` m¤¢e nq, Z‡e we‡kl‡Ái civgk© wbb|  cvwicvwk©¦K mgm¨v ev` w`b: ▸ gv‡qi ev cÖavb hZœKvixi g‡a¨ gvSvix-¸iæZi welYœZv Av‡Q wKbv (>> DEP)| ▸ DÏxcbvi Afve (Kg eqmx wkïi †gav weKv‡k DÏxcbv ¸iæZ¡c~Y©) ∙ wkïi mv‡_ †K wbqwgZ K_vevZ©v e‡j I †Ljvayjv K‡ib? ∙ Avcwb/Zviv wKfv‡e wkïi mv‡_ †L‡jb? KZÿY? ∙ Avcbvi wkïi Avcwb/Zviv wKfv‡e †hvMv‡hvM K‡i? KZÿY?  Acywó I Av‡qvwW‡bi Afve I nvB‡cv_vBi‡qwWmg*mn Ab¨vb¨ cywó ev ni‡gv‡bi NvUwZ _vK‡j ev` w`b|  g„Mx‡ivM (>>EPI) _vK‡j ev` w`b, †hUv eyw× cÖwZewÜZvi mv‡_ mv‡_ NU‡Z c‡i wKsev Abyiƒc n‡Z cv‡i| » wPwýZ wPwKrmv‡hvM¨ mgm¨vmg~‡ni e¨e ’¯vcbv Kiæb Ges e¨w³i eyw× cÖwZewÜZv Av‡Q wK-bv, Zv hvPvB Ki‡Z cybivq A¨v‡mm Kiæb|  kªeY I „`wónxbZv wbwðZ n‡j h_vh_ mnvqZv cÖ`vb Kiæb ev mvnvh¨ Kiæb (Pkgv, Kv‡b †kvbvi hš¿)|  cÖ‡hvR¨ n‡j hZœKvixi welYœZvi e¨e¯’vcbv wbb|  Kg eqmx wkï‡K wKfv‡e Av‡iv DÏxcK cwi‡ek †`qv hvq, †m e¨vcv‡i hZœKvix‡K wkÿv w`b| KvD‡Ýj `¨v d¨wgwj di †Kqvi di †W‡fjc‡g›U: KvD‡Ýwjs KvW©m †`Lyb (BDwb‡md I WweøDGBPI, 2012)|  Dchy³ n‡j e¨w³‡K cÖv_wgK wkï Dbœqb (BwmwW) Kg©m~wP‡Z cvVvb| » eyw× cÖwZewÜZv n‡Z cv‡i hw` K) Kvw•ÿZ weKvk gvBjdj‡K †cuŠQv‡Z D‡jøL‡hvM¨ wejw¤Z^ nq Ges ˆ`bw›`b Pvwn`v c~i‡Y mgm¨v nq Ges L) wPwKrmv‡hvM¨ I cwieZ©b‡hvM¨ Ae ’¯vmg~n ev` †`qv nq A_ev e¨e ’¯v †bqv nq| A¨v‡mm‡g›U cÖkœ 2: mn‡hvMx AvPiYMZ mgm¨v Av‡Q wK? » hZœKvixi K_v bv †kvbv » e`‡gRvRx, AvMÖvmx I nZvk n‡j wb‡Ri ÿwZ Kivi cÖeYZv| » A‰Re wRwbl LvIqv » Awbqwš¿Z †hŠb ev Ab¨vb¨ mgm¨vMZ AvPiY| 53 g~j wPwKrmv cwiKíbv 1. mvB‡KvGWz‡Kkb w`b » e¨w³ I Zvi hZœKvix‡`i Kv‡Q cÖwZewÜZv e¨vL¨v Kiæb| GB cÖwZewÜZvi Rb¨ eyw× cÖwZeÜx e¨w³‡K †`vlv‡ivc Kiv DwPZ bq| j¶¨ n‡”Q, hZœKvix †hb ev ͯe cÖZ¨vkv iv‡Lb Ges mü`q I mnvqK nb| » AwffveK `ÿZv cÖwk¶Y w`b| j¶¨ n‡”Q, wkï I Zvi wcZv- gvZv / hZœKvixi g‡a¨ BwZevPK m¤cK© Dbœqb| hZœKvix‡K `ÿZv cÖwkÿY w`b hv AvPiYMZ mgm¨v Kg‡Z mvnvh¨ Ki‡e|  hZœKvix‡K eyS‡Z n‡e e¨w³‡K wb‡Ri hZœ I cwi”QbœZv †kLv‡bvi ¸iæZ¡ (†hgb, Uq‡jU cÖwkÿY, u`vZ eªvk Kiv)|  e¨w³ m¤c‡K© hZœKvix‡K Lye fv‡jv aviYv ivL‡Z n‡e| hZœKvix‡K Rvb‡Z n‡e, †KvbUvq e¨w³i gvbwmK Pvc ˆZwi K‡i Ges †KvbUvq Avbw›`Z nq, †Kvb Kvi‡Y AvPiYMZ mgm¨v ˆZwi nq Ges wK Zv‡`i wbe„Z K‡i, †ivMxi kw³kvjx/mej I y`e©j w`K¸‡jv wK wK Ges wKfv‡e e¨w³ me‡P‡q fv‡jv wkL‡Z cvi‡e|  e¨w³i cÖvZ¨wnK Kvh©µg †hgb, LvIqv-`vIqv, †Ljv, †kLv, KvR Kiv Ges Nygv‡bv hZLvwb m¤¢e wbqwgZ ivL‡Z n‡e|  hZœKvix cyi¯‹vi †`‡eb hLb e¨w³ fv‡jv AvPiY Ki‡e Ges cyi¯‹vi cÖZ¨vnvi K‡i †b‡eb, hLb e¨w³i AvPiY mgm¨vc~Y© n‡e| fvimvg¨c~Y© k„•Ljv eRvq ivLyb: ▸ †Kvb KvR Kiv DwPZ I †Kvb KvR Kiv DwPZ bq, †m e¨vcv‡i e¨w³‡K ¯có, mij I †QvU wb‡`©kbv w`‡Z n‡e| RwUj KvR‡K †f‡O †QvU †QvU As‡k fvM K‡i w`b, hv‡Z e¨w³ wkL‡Z cv‡i Ges GKev‡i GK av‡c cyi®‹vi †c‡Z cv‡i (†hgb- †evZvg jvMv‡bvi Av‡M UªvDRvi civ †kLv)| ▸ e¨w³ hLb fv‡jv KvR K‡i, cyi®‹vi w`b| e¨w³i hv Kiv DwPZ bq, Zv †_‡K Zvi g‡bv‡hvM mwi‡q ivLyb| hv‡nvK, Ggb g‡bv‡hvM mwi‡q ivLv e¨w³i Rb¨ myLKi I cyi®‹viRbK bvI n‡Z cv‡i| ▸ mgm¨vc~Y© AvPi‡Yi Rb¨ ûgwK ev kvixwiK kvw¯Í †`‡eb bv| » hZœKvix‡K wkÿv w`b †h e¨w³wU kvixwiK I †hŠb wbh©vZ‡bi A‡bK SzuwK‡Z Av‡Q, mvaviYfv‡e ZvB Zvi cÖwZ AwZwi³ g‡bv‡hvM I myiÿv wbwðZ Ki‡Z n‡e| » cÖvwZôvwbKZv Gov‡Z hZœKvix‡K wkÿv w`b| 2. KwgDwbwUwfwËK myiÿv e„w× Kiæb » KwgDwbwUwfwËK myiÿvi jf¨Zv hvPvB Kiæb (†hgb, N‡ivqv `j, ¯’vbxq GbwRI, miKvwi I AvšÍR©vwZK ms ’¯vmg~n) Ges e¨w³i Rb¨ mswkøó mnvqZv Pvb| 3. KwgDwbwU Kvh©µ‡g AšÍfy©w³i Rb¨ cÖPviYv Pvjvb » e¨w³ hw` wkï n‡q _v‡K, hZLvwb m¤¢e Zv‡`i mvaviY ¯‹z‡j ivLyb|  wk¶Yxq cwi‡e‡k wkïi Lvc LvIqv‡bvi m¤¢vebv AbymÜv‡bi Rb¨ wkïi ¯‹y‡ji mv‡_ †hvMv‡hvM Kiæb| mnR Dcvq i‡q‡Q ÒBbK¬ywmf GWz‡Kkb wPj‡Wªb A¨vU wi¯‹Ó (INEE) G| » KwgDwbwUi Dc‡fvM¨ mvgvwRK Kg©Kv‡Ð AskMÖn‡Yi Rb¨ Drmvn w`b| » KwgDwbwUwfwËK cybe©vmb (CBR*) Kg©m~wPi jf¨Zv hvPvB Kiæb Ges G ai‡bi Kg©m~wP‡Z eyw× cÖwZeÜx e¨w³i AšÍf‚©w³ wb‡q cÖPviYv Pvjvb| 4. gvbwmK Pvc Kgv‡bv I mvgvwRK mnvqZv kw³kvjxKi‡Yi bxwZ (>> †mevi mvaviY g~jbxwZ) Abyhvqx hZœKvixi hZœ wbb 5. hw` m¤¢e nq, m¤¢ve¨ mgmvgwqK weKvkgvb Ae¯’vmg~n Rvb‡Z Av‡iv A¨v‡mm‡g›U I e¨e ’¯vcbvi Rb¨ GKRb we‡kl‡Ái Kv‡Q cvVvb » †ckx mÂvj‡b AcwieZ©b‡hvM¨ ˆeKj¨ A_ev †mwieªvj cvjwm* » Rb¥ ÎæwU, wRbMZ A¯^vfvweKZv ev wm‡Ûªvg (†hgb, WvDb wmb‡Wªvg) 6. d‡jv-Avc » e¨e¯’vcbvi bxwZgvjv (>> †mevi mvaviY g~jbxwZ) Abyhvqx d‡jv-Avc †mk‡bi Rb¨ mgqZvwjKv wVK Kiæb I cwiPvjbv Kiæb| e· AvBwW 1: µgweKv‡ki gvBjdjK: †Lqvj ivLvi g‡Zv mZK©Zvi jÿYmg~n 1 gvm eq‡mi g‡a¨  gv‡qi y`a wVKfv‡e Lvq bv ev †L‡Z Pvq bv  nvZ I cv‡qi Kg bovPov  D”P kã ev D¾¡j Av‡jvi cÖwZ Kg mvov †`qv ev G‡Kev‡iB bv †`qv  ewg I Wvqwiqv, hv cvwbk~b¨Zv ˆZwi Ki‡Z cv‡i 6 gvm eq‡mi g‡a¨  RoZv ev A½-cÖZ¨½ bvov‡Z mgm¨v  evievi gv_v bvov‡bv (GUv Kv‡b msµgY wb‡`©k Ki‡Z cv‡i, hvi wPwKrmv bv n‡j kÖeYkw³ bó n‡q †h‡Z cv‡i  kã, cwiwPZ gyL ev ey‡Ki y`‡a Kg mvov †`qv A_ev G‡Kev‡iB bv †`qv  ey‡Ki y`a ev Ab¨vb¨ Lvevi cÖZ¨vL¨vb Kiv 12 gvm eq‡mi g‡a¨  A‡b¨i mvovk‡ãi Rev‡e †Kvb kã bv Kiv  Pjgvb e ‘¯i w`‡K bv ZvKv‡bv  hZœKvixi cÖwZ wbiærmvnx ev cÖwZwµqvi Afve  ÿzav Kg A_ev Lvevi cÖZ¨vL¨vb Kiv 2 eQi eq‡mi g‡a¨  Ab¨‡`i cÖwZ mvov bv †`qv  nuvUvi mgq fvimvg¨ ivLvi mgm¨v  AvNvZ cvIqv Ges AvPi‡Y e¨vL¨vnxb cwieZ©b (we‡kl K‡i wkïwU‡K hw` Ab¨ †KD †`Lfvj K‡i)  ÿzav Kg 3 eQi eq‡mi g‡a¨  †Ljvayjvq AvMÖn nviv‡bv  evievi c‡o hvIqv  †QvULv‡Uv wRwbm cwiPvjbv Ki‡Z mgm¨v  mnR evZ©v †evSvi e¨_©Zv  K‡qKwU kã w`‡q K_v ej‡Z bv cviv  Lvev‡ii cÖwZ AvMÖn Lye Kg ev G‡Kev‡iB bv _vKv 5 eQi eq‡mi g‡a¨  Ab¨ ev”Pv‡`i mv‡_ †Lj‡Z wM‡q fq, ivM ev mwnsmZv, hv Av‡eMxq mgm¨v ev wbh©vZ‡bi jÿY n‡Z cv‡i 8 eQi eq‡mi g‡a¨  eÜzZ¡ Ki‡Z I ivL‡Z Ges `jxq Kvh©Kjv‡c Ask wb‡Z mgm¨v  †Póv QvovB KvR ev P¨v‡jÄ Gov‡bv, A_ev Amnvq‡Z¡i jÿY †`Lv‡bv  PvIqv-cvIqv, wPšÍv I Av‡eM cÖKv‡ki mgm¨v  Kv‡R g‡bv‡hvM w`‡Z, ¯‹z‡ji KvR eyS‡Z I †kl Ki‡Z mgm¨v  eÜz I cwiev‡ii mv‡_ AwZwi³ AvMÖvmb ev j¾v m~Î: BDwb‡md, BD‡b‡¯‹v, BDGbGdwcG, BDGbwWwc, BDGbGAvBwWGm, WweøDGdwc Ges wek¦ e¨vsK (2010) 55 A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Rxe‡bi SyuwKg~jK A¨vj‡Kvnj cÖZ¨vnv‡ii A¨v‡mm‡g›U I e¨e¯’vcbvi Rb¨ c„ôv 48 Gi e· GmBDwe 1 †`Lyb A¨vj‡Kvnj ev gv`‡Ki Ace¨envi (†hgb: Avwdg*(†n‡ivBb), MvuRv*, GgwdUvwgb*, LvZ*,wewfbœ ai‡bi e¨e¯’vc‡Îi Jla †hgb †eb‡RvWvqv‡Rwcb* Ges UªvgvWj)| cÖZ¨vnvi (e¨env‡ii gvÎv Zvrch©c~Y©fv‡e K‡g †M‡j †hai‡bi kvixwiK Ges gvbwmK j¶Y †`Lv †`q), wbf©ikxjZv* Ges ¶wZKi e¨envi (kvixwiK wKsev gvbwmK Ges ¯^vfvweK mg„w×i ¶wZ K‡i)| g`¨cvb Ges Jly‡ai e¨envi ¶wZKi hLb Gi Kvi‡Y kvixwiK wKsev gvbwmK Amy ’¯Zv †`Lv †`q, ¯^v ’¯¨nvwb nq Ggb AvPiY, cvwievwiK/ AšÍi½ m¤c‡K© mgm¨v, †hŠb Ges kvixwiK mwnsmZv, `~N©Ubv, wkï wbh©vZb Ges AhZœ, A_©‰bwZK `y ©`kv Ges Ab¨vb¨ wbivcËvRwbZ welq †`Lv †`q| g`¨cvb Ges Jly‡ai e¨env‡ii gvÎv Riæwi gvbweK Ae¯’vi mgq hviv G mgq cÖvß-eq¯‹ Ges eqtmw܇Z hviv _v‡K Zviv gvbwmK Pv‡ci mv‡_ Lvc LvIqvi Rb¨, nviv‡bv wKsev Kó †_‡K †ei nevi Rb¨ wb‡R Ilya †meb* †e‡o hvq| Zxeª Riæwi Ae¯’vi Kvi‡Y g`¨cvb Ges Jly‡ai †hvMvb e¨vNvZ NU‡Z cv‡i, hvi d‡j hviv A‡bKw`b a‡i AwZwi³ gvÎvq Jla †meb K‡i _v‡K †m ai‡bi e¨w³i g‡a¨ cÖZ¨vnviRwbZ j¶Y †`Lv w`‡Z cv‡i hv LyeB AcÖZ¨vwkZ RxebûgwK¯^iƒc| GUv we‡kl K‡i hviv g`¨cvb K‡i _v‡K Zv‡`i †¶‡Î mZ¨| GB gwWDjwU g`¨cvb Ges Jla e¨env‡ii ¶wZKi cÖfv‡ei Dci j¶¨ iv‡L Ges RxebûgwK¯^iƒc g`¨cvb cÖZ¨nvi m¤cwK©Z Z_¨ e‡·i g‡a¨ AšÍf©z³ Av‡Q (e· Dc-1)| g`¨cvb Ges Jla e¨env‡ii welqe ‘¯ fv‡jvfv‡e †evSvi Rb¨, g`¨cvb Ges Jla e¨env‡ii GgGBPM¨vc wPwKrmv c×wZi gwWDjwU †`Lyb| Dc ’¯vwcZ Awf‡hvMmg~‡ni bgybv: » g`¨cvb wKsev gv`‡Ki cÖfv‡e cÖKvkgvb j¶Y (g‡`i MÜ, †bkvMÖ¯’ †`Lv‡bv, Aw¯’i nIqv, D‡ËRbv, wb®úÖvY nIqv, AcgvbRbK K‡_vcK_b, G‡jv‡g‡jvfve, eo †PvL/msKzwPZ †PvL*) » mv¤cÖwZK `yN©Ubv » WªvM †bevi mgq †bevi (AvB.wf) wPý (Bb‡RKk‡bi wPý, Pg© msµgY) » Ny‡gi wKsev e¨_vbvkK Jl‡ai Rb¨ Aby‡iva Kiv| S U B 45 SUB 57 A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1: g`¨cvb wKsev Jlya †me‡bi Kvi‡Y wK †Kvb mvaviY my¯’Zv Ges kvixwiK Ges gvbwmK ¯^v¯’¨ ¶wZi m¤§yLxb n‡Z cv‡i?  †Kvb ai‡bi mgv‡jvPbv QvovB g` wKsev Jlya †me‡bi we ͯvwiZ Rvb‡Z n‡e  Rvbybt ◆◆e¨env‡i cwigvY Ges aibt ▸▸Avcwb wK g`¨cvb K‡ib? hw` K‡ib Z‡e wK fv‡e K‡ib? cÖwZ w`b wKsev mßv‡n KZevi †bb? ▸▸Avcwb wK Ny‡gi Jlya| y`wðšÍv Kgv‡bvi Jlya/ e¨_vbvkK e¨envi K‡ib? wK ai‡bi?cÖwZw`b ev mßv‡n wK cwigvY? ▸▸Avcwb wK A‰ea Jlya e¨envi K‡ib? wK ai‡bi? wKfv‡e wbb †m¸‡jv- gyL, Bb‡RKkb Gi gva¨‡g? wK ai‡bi?cÖwZw`b ev mßv‡n wK cwigvY? ◆◆A¨vj‡Kvnj wKsev Jlya †me‡bi DÏxcKmg~n ▸▸wK Kvi‡Y Jlya wKsev g` †L‡Z B”Qv K‡i Avcbvi? ◆◆wb‡Ri wKsev A‡b¨i ¶wZmvab Kivt †Kvb †ivM ev AvNvZ A¨vj‡Kvnj ev Jla †me‡bi Kvi‡Y ▸▸g`¨cvb wKsev Jlya †me‡bi Kvi‡Y †Kvb ai‡bi kvixwiK mgm¨v wKsev AvNvZ †c‡q‡Q wKbv? ∙∙g`¨cvb wKsev gv`‡Ki †me‡bi Kvi‡bi †Kvb ai‡bi ¯^v ’¯¨RwbZ mgm¨vi g‡a¨ c‡i‡Qb wKbv? ∙∙g`¨cvb wKsev gv`‡Ki †me‡bi Kvi‡Yi AvNvZ †c‡q‡Qb wKbv? ▸▸Dc‡`k D‡cÿv K‡i g`¨cvb ev gv`K †meb eÜ bv Kivi e`‡j Pvwj‡q hvIqv ∙∙hLb Mf©eZx wKsev gvZ…`y» cvb Kivb ∙∙ hLb e¨w³ Rvbvq †h GLv‡b †Kvb mgm¨v Av‡Q ∙∙hLb e¨w³ Rvbvq †h g`¨cvb wKsev gv`K †me‡bi Kvi‡Y Zvi cvK ’¯jx wKsev hK…‡Z mgm¨v †`Lv w`‡q‡Q| ∙∙e¨e ’¯vc‡Îi Jl‡ai mv‡_hLb e¨w i³ g`¨cvb wKsev gv`K †me‡bi Ab¨vb¨ ¶wZKi cÖfveI wg‡j hvq, †hgb Nyg, †e`bvbvkK, wKsev wUEevi wKD‡jvwm‡mi Jlya| ▸▸ g`¨cvb wKsev gv`K †me‡bi Kvi‡Y mvgvwRK mgm¨vt ∙∙A_©‰bwZK wKsev AvBwb mgm¨v ∙∙g`¨cvb wKsev gv`K ª`e¨ †me‡bi Kvi‡Y KL‡bv UvKvi wKsev AvBbf‡½i mgm¨vq c‡o‡Qb? ∙∙ †ckvRwbZ mgm¨v ∙∙g`¨cvb wKsev Jlya †me‡bi Kvi‡Y KL‡bv PvKwi nvwi‡q‡Q ev PvKwi‡Z Lvivc K‡i‡Qb? ∙∙Avcbvi wkï wKsev Ab¨vb¨ wbf©ikxj gvby‡li †Lqvj ivL‡Z mgm¨v n‡q‡Q ∙∙Avcwb wK KL‡bv KL‡bv †Lqvj K‡i‡Qb g`¨cvb wKsev Jlya †me‡bi Kvi‡Y e¨w³i Zvi cwievi Ges mšÍv‡bi †Lqvj ivL‡Z Kó n‡q‡Q? ∙∙A‡b¨i cÖwZ mwnsm AvPiY Kiv ∙∙g`¨cvb wKsev Jlya †me‡bi Kvi‡Y KvD‡K AvNvZ K‡i‡Qb wK? ∙∙ m¤cK©/ ˆeevwnK m¤c‡K© mgm¨vt ∙∙g`¨cvb wKsev Jlya †me‡bi Kvi‡Y Rxeb m½xi mv‡_ KL‡bv wK mgm¨v nqwb?  g`¨cvb wKsev Jlya †me‡bi †Kvb `xN© ’¯vqx kvixwiK mgm¨v n‡q‡Q wKbv Zv Lye ª`yZ †`‡L wb‡Z n‡e| ◆◆Gastrointestinal bleeding: ▸▸†c‡U e¨_v ▸▸i³ ewg ▸▸cvqLvbvi mv‡_ i³ hvIqv wKsev Kv‡jv cvqLvbv ◆◆hK…‡Zi Amy¯’Zv ▸▸gvivË¡Kt RwÛm, Gmwm‡UQ*, hK…Z eo Ges k³n‡q hvIqv I wc‡j nIqv, †ncvwUK G‡Ýdv‡jvc¨w_*| ◆◆Acywó, gvÎvwZwiK IRb K‡g hvIqv| ◆◆Jly‡ai Gi mv‡_ wgwjZ msµg‡bi cÖgvY ( †hgb GBPAvBwf, †ncvUvBwUm we wKsev wm, †hLv‡b m~P †`Iqv nq †mLv‡b msµgb wKsev wUDeviwKD‡jvwmm)| ▸▸g`¨cvb wKsev Ab¨vb¨ gv`K †meb K‡i Ggb e¨w³ cÖvqB GB ¶wZKi w`Kmg~n GKB mv‡_ wba©viY Ki‡Z n‡e †Kbbv GB †ivMmg~n cÖvqB GKB mv‡_ N‡U| S U B g~j wPwKrmv cwiKíbv 1| g`¨cvb wKsev gv`K ª`e¨ †me‡bi ¶wZKi cÖfv‡ei e¨e ’¯vcbv  g`¨cvb wKsev gv`K ª`e¨ †me‡bi Kvi‡Y hw` kvixwiK fv‡e ÿwZMÖ¯Í nq Ges wPwKrmvi cÖ‡qvRb nq, Z‡e Zv cÖ`vb Ki‡Z n‡e|  Riæwi mvgvwRK cwiw¯’wZ wPwýZ Ki‡Z n‡e (†hgbt wbh©vZ‡bi †¶‡Î wbivcËv †mevi mv‡_ †hvMv‡hvM Ki‡Z n‡e n‡Z cv‡I †RÛvi †em&W fv‡qv‡jÝ)|  mgmvgwqK Ab¨†gwW‡Kj KwÛkb _vK‡j Zv wbqš¿Y Ki‡Z n‡e, †hgb gvSvwi †_‡K Zxeª welYèZv, wcwUGmwW Ges mvB‡Kvwmm (>> wWBwc, wcwUGmwW, mvB)| 2| g`¨cvb wKsev gv`K †meb eÜ Kiv wKsev Kgv‡bvi Rb¨ e¨w³i wZeª B”Qv Av‡Q wKbv Zv hvPvB K‡i wb‡Z n‡e  g`¨cvb wKsev gv`K †meb‡K †Kvb mgm¨v wn‡m‡e †`‡L wKbv Zv hvPvB Ki‡Z n‡e Ges hw` e¨w³ ˆZwi _v‡K Z‡e wZwb wKQ z Ki‡Z Pvb wKbv  Avcbvi wK g‡b nq g`¨cvb wKsev gv`K †me‡b †Kvb mgm¨v Av‡Q?  Avcbvi KL‡bv Zv eÜ wKsev Kgv‡bvi fvebv G‡m‡Q?  eÜ wKsev Kgv‡bvi Rb¨ c~‡e© †Kvb cÖ‡Póv K‡iwQ‡jb? 3|g`¨cvb wKsev Jla †meb eÜ Kiv wKsev Kgv‡bvi Rb¨ e¨w³‡K †cÖlYv wKsev DrmvwnZ Ki‡Z n‡e|  ¶wZKviK cÖfve wb‡q GKwU mswÿß Drmvng~jK K‡_vcK_b ïiæ Ki‡Z n‡et  g`¨cvb wKsev Jla †me‡b e¨w³i †Kvb DcKvi Ges ¶wZ nq wKbv Zvi m¤c‡K© Rvb‡Z n‡e| wb‡i‡c¶fv‡e †evSvi †Póv Ki‡Z n‡e †h †Kvb welq mg~n e¨w³‡K g`¨cvb wKsev Jla †me‡bi w`‡K PvwjZ K‡i| ▸▸Avcwb wK g`¨cvb wKsev gv`K †meb K‡i wK ai‡bi Avb›` cvb? ▸▸g`¨cvb wKsev gv`K †me‡bi †Kvb ¶wZKi w`K wK Avcwb †`L‡Z cvb? ▸▸g`¨cvb wKsev Jlya †me‡bi Kvi‡Y AbyZß Abyfe K‡ib?  e¨w³ hw` g`¨cvb wKsev gv`K †me‡bi †Kvb AwZiwÄZ DcKvwiZv †c‡q _v‡K Z‡e Zv‡K mivmwi cÖkœ Kiæb? †hgbt hw` e¨w³ g`¨cvb wKsev gv`K †me‡bi gva¨‡g Rxe‡bi mgm¨v fz‡j _vK‡Z Pvq, Z‡e ejybt ▸▸mgm¨v fz‡j _vKvUv wK Avm‡jB fv‡jv wKQz? Gfv‡e wK Avcbvi mgm¨v P‡j hv‡e?  g`¨cvb wKsev Jla †me‡bi d‡j †hme mgm¨v †`Lv †`q †m¸‡jv D‡jøL Kiæb †h¸‡jv e¨w³ nqZ Zvrch©c~Y© fv‡e †`‡L bv| ▸▸g`¨cvb wKsev Jla †meb Kivi Rb¨ wK cwigvY A_© e¨q K‡ib? cÖwZ mßv‡n? cÖwZ gv‡m? cÖwZ eQ‡i? GB A_© w`‡q Avcwb AviI wK wK Ki‡Z _vK‡Z cvi‡eb?  g`¨cvb wKsev gv`K ª`e¨ †me‡bi `xN©¯’vqx Ges ¯^í¯’vqx ¶wZKviK cÖfve wb‡q AviI AwZwi³ Z_¨ w`b|  A¨vj‡Kvnj ev gv`K`ªe¨ †me‡bi Kvi‡Y †h me mgm¨v n‡Z cv‡i Zv n‡j ¸iæZi †gwW‡Kj ev gvbwmK mgm¨vmg~n, †m mv‡_ i‡q‡Q RLg Ges Avmw³|  ¯ ^xKvi K‡i wbb†h g`¨cvb wKsev Jlya †meb eÜ Kiv KóKi| Avcwb Zv‡K Rvbvb †h Avcwb Zv‡K mvnvh¨ Ki‡Z B”QzK| †jvK‡`i Drmvn w`b hv‡Z Zviv wb‡RB wm×všÍ wb‡Z cv‡i, hw`I GwU fvj aviYv g`¨cvb wKsev gv`K †meb eÜ Kiv|  hw` e¨w³ g`¨cvb wKsev gv`K †meb eÜ Ki‡Z bv Pvq Z‡e Zv‡`i wm×všÍ‡K m¤§vb Kiæb| Zv‡`i Kv‡Q Rvb‡Z Pvb †h cieZ©x‡Z Zviv K‡e G‡m GB welq wb‡q K_v ej‡Z Pvq|  mswÿß Drmvng~jK K‡_vcK_b cieZ©x K‡qKwU †mk‡b evi evi Av‡jvPbv Kiæb hv Dc‡i eY©bv Kiv n‡q‡Q| S U B 4| Kgv‡bv wKsev eÜ Kivi bvbvb c×wZ wb‡q Av‡jvPbv Kiæb|  wb‡¤œv³ c×wZmg~n Av‡jvPbv Kivt  evmvq g` wKsev Jla Rgv bv ivLv|  †hme RvqMvq mn‡R g` wKsev gv`K ª`e¨ cvIqv hvq †mLv‡b bv hvIqv  †mev`vbKvix Ges eÜz‡`i mg_©b PvIqv|  †mev`vbKvix‡K d‡jv-Avc †mk‡b e¨w³i mv‡_ Avm‡Z ejv|  g` wKsev Jla Qvov mvgvwRK Kg©Kv‡Ð DrmvwnZ Kiv|  hw` _v‡K Z‡e, A¨vj‡Kvnj ev gv`‡Ki e¨env‡ii wbR-mvnvh¨ `‡j †hvMv‡hvM Kwi‡q †`Iqv|  hw` g`¨cvb wKsev Jla †meb eÜ Ki‡Z Pvq Z‡e Zv‡K cÖZ¨vnv‡ii DVwZ mvgwqK jÿYmg~‡ni m¤c‡K© Z_¨ cÖ`vb Kiv (†hgbt 1 mßv‡ni Kg)|  j¶Ymg~n eY©bv Kiv (Avwds, †eÄWvqv‡RcvBb&m Ges g‡`i cÖZ¨vnv‡ii d‡j D‡ØM Ges Aw¯’iZv †`Lv †`q)| hw` j¶Y AwZ gvÎvq †`Lv †`q Z‡e e¨w³‡K ejyb `ªæZ nvmcvZv‡j †h‡Z| 5| mvgvwRK mg_©b e„w× Ges Pvc Kgv‡bvi g~jbxwZ¸‡jv g‡bv-mvgvwRK mnvqZv wn‡m‡e cÖ`vb Kiæb (>> †mevi mvaviY g~jbxwZ)  g‡bv-mvgvwRK Pvcmg~‡ni KviY¸‡jv wPwýZ Kiv  mvgvwRK mg_©b evov‡bv  gvbwmK Pvc wbqš¿Y †kLv‡bv 6|cÖwZwbqZ d‡jv-Avc cÖ`vb  A¨vj‡Kvnj ev gv`K †meb Kgv‡bvi Rb¨ †mev`vbKvix Ges e¨w³‡K cÖwZwbqZ mnvqZv, Av‡jvPbv Ges GK mv‡_ KvR K‡i †h‡Z n‡e| wbqwgZ d‡jv-Avc †mk‡b Av‡qvRb Kiv Ges mgqZvwjKv Kiv| (>> e¨e ’¯vcbvi g~jbxwZmg~n †mevi mvaviY g~jbxwZ‡Z) 59 Box SUB 1 Rxeb SzuwK‡Z †d‡j Ggb g` cv‡bi †bkvi A¨v‡mm‡g›U I cÖwZKvi GLv‡b GKRb e¨w³i Rxeb SzuwKg~jK A¨vj‡Kvnj cÖZ¨vnv‡ii jÿYmg~n Dc ’¯vcb Kiv n‡”Q » DrKÉv, cÖPÐ D‡ØM » Kbfvjkb/wLuPzbx » wPšÍvfvebvq wek„•LjZv A_ev AjxK wKQz †`Lv*(Ggb wKQz †`Lv, †kvbv ev Abyfe Kiv hvi Aw ͯZ¡ †bB) » AwZwi³ i³Pvc ev ü`K¤úb (>180/100 GgGg GBPwR) Rxeb ûgwK‡Z †d‡j Ggb g`¨cv‡bi †bkvi G‡mm‡g›U G‡mm‡g›U cÖkœ 1: GUv wK g` cÖZ¨vnv‡ii jÿY? » Ab¨vb¨ Kvi‡Yi g‡a¨ mwVK KviYwU wbe©vPb Kiæb| †hUvi gva¨‡g j¶Y¸‡jv wVKVvK e¨vL¨v Kiv hvqt  g¨v‡jwiqv| GBP AvB wf/GBWm, Ab¨vb¨ Bb‡dKkvb, gv_vi AvNvZ, nR‡gi mgm¨v* ( †hgbt nvB‡cvMøvB‡mwgqv*, nvB‡cvbvUªvwgqv*), †ncvwUK Gb‡mdv‡jvc¨vw_, nvBcviw_IBwWRg*, †÷ªvK, WªvM e¨envi (GwçUvwgb&m) mvB‡Kvwmm I g„wM‡ivM Gi BwZnvm| » Dc‡ii KviY¸‡jv evwZj K‡i †`evi ci, Zvi g` cv‡bi BwZnvmRvb‡Z Pvb Zvi wKsev Zvi ZË¡eavq‡Ki KvQ †_‡Kt  e¨w³ wK g` Lvb?  †m †kl K‡e g` †L‡qwQ‡jb?  mvaviYZ wK cwigvY Lvb?  g` Avmw³i j¶Ymg~‡ni g‡a¨ wbqwgZ/†ewk g` cv‡bi weiwZi d‡j nq| GUv mvaviYZ g` cv‡bi 1/2 w`b ci †`Lv hvq|  hw` e¨w³i wLuPzbx ev AjxK åg/ n¨vjywm‡bkb n‡q _v‡K wKš‘ Zv hw` g` Avmw³i †Kvb cÖgvY bv cvIqv hvq , Z‡e e¨w³i †ivMwU wg„wM †ivM (>>EPI)ev mvB‡Kvwmm (>>PSY) G‡mm Ki‡Z n‡e| G‡mm‡g›U cÖkœ 2: hw` e¨w³i g` cÖZ¨vnv‡ii jÿY †_‡K _v‡K, Z‡e Zv wK Rxeb SzuwK‡Z †djv g` cÖZ¨vnv‡ii jÿY? » Rxeb SzuwK‡Z †djv ˆewk󨸇jv wba©viY Kiæb:  Kbfvjkb/wLuPzbx mgm¨v (mvaviYZ 48 N›Uv ci ci)  †Wwjwiqv‡gi* ˆewkó¨ (mvavibZ 96 N›Uv ci ci)  cÖPÛ wek„•Lj wPšÍvfvebv, wePvieyw× KvR bv Kiv  AjxK Abyf‚wZ ev `k©b/ n¨vjywm‡bkb » G‡mm Kiæb e¨w³i Rxeb SzuwK‡Z †dj‡Z cv‡i Ggb ˆewkó¨ ¸‡jv AviI evo‡Q wKbv Zv (wLuPzwb A_ev †Wwjwiqvg) cieZ©x 1-2 w`bt  c~‡e©i Rxeb SzuwKi ‰ewkó¸‡jv (wLuPzwb A_ev wLuPzbx) A_ev  eZ©gv‡b Ges ¸iæZi g` cÖZ¨vnv‡ii j¶Y:  cÖPÛ DrKÉv, A‡bK weiw³, A‡bK D‡ØM  †ewk †ewk Nvgv, nvZ Kvucv  AwaK D”P i³Pvc ( †hgbt > 180/100 GgGg GBPwR)/ A_ev ü` K¤cb ( †hgb>100 wewcGg)| Riæwi e¨e ’¯vcbv cwiKíbv Rxeb SzuwK‡Z c‡o Ggb A¨vj‡Kvnj cÖZ¨vnv‡ii jÿYmg~‡ni Rb¨ 1. Wvqv‡Rcvg w`‡q gv`K cÖZ¨vnv‡ii wPwKrmv (>> Table SUB 1)  wPwKrmvi †¶‡Î Wvqv‡Rcv‡gi †WvR wbf©i K‡i e¨w³ mn¨ ¶gZvi Dci*, cÖZ¨vnv‡ii d‡jj¶‡Yi gvÎv, Ges Ab¨vb¨ we`¨gvb †ivMmg~‡ni Dci|  †WvR‡K „`k¨gvb cÖfv‡ei mv‡_ mvgÄm¨ Ki‡Z n‡e| mwVK †WvRwU n‡e ZvB hv Kg D‡ËwRZ K‡i|  †WvR †ekxgvÎvq evo‡j AwZwi³ wm‡Wkb Ges k¦vm nªvm †c‡Z cv‡i| cÖvqkB ZvB e¨w³i k¦mb gvÎv Ges wm‡Wkb cwigvc Ki‡Z n‡e|  Avevi A‡bK Kg gvÎvi †Wv‡Ri Kvi‡b wLuPzbx/wW‡jwiqvg †`Lv w`‡Z cv‡i|  Acmvi‡Yi j¶Y cÖvqkB Z`viwK Kiæb (cÖwZ wZb-Pvi N›Uv ci ci) hZ¶Y bv j¶Y ~`i n‡”Q Wvqv‡Rcvg e¨envi Kiæb ( mvaviYZ 3-4 w`b Z‡e 7 w`‡bi †ewk Aek¨B bq)|  wmRv‡ii †¶‡Î Gw›U Gwc‡jwÞK e¨envi Kiv hv‡ebv, Wvqv‡Rcvg e¨envi Kiæb|  †Wwjwiqv‡gi †¶‡Î wØav, Aw ’¯iZv, †njywm‡bkb Gme j¶Y cÖvq K‡qK mßvn Gi g‡Zv _v‡K Ab¨vb¨ cÖZ¨vnviRwbZ jÿY P‡j hvq| G‡¶‡Î Gw›UmvB‡KvwUK †gwWwmb e¨envi Kiv †h‡Z cv‡i †hgb †n‡jv‡cwiWj 2.5-5 wg.MÖv. gy‡L Lv‡e, w`‡b wZbevi K‡i †m‡i DVevi AvM ch©š Í| Ifvi wm‡Wk‡bi w`‡K wb‡q hv‡eb bv|  hw` m¤¢e nq, GKwU kvšÍ, D‡ËRbv †bB Ges fv‡jv cwi‡e‡k ivLvi e¨e ’¯v Kiæb| gvS iv‡Î †ivMx †R‡M †h‡Z cv‡i weavq iv‡ÎI Av‡jvi e¨e ’¯v Kiæb| y`N©Ubv Gov‡Z e¨w³‡K †g‡S‡Z ivLv k³ Mw`‡Z ivLvi e¨e¯’v Kiæb| m¤¢e n‡j GKRb Zvi †`Lfvj Gi Rb¨ GKRb mve©¶wbK gvbyl ivLyb| wbqš¿Y Gwo‡q Pjyb| 2. cywónxbZv G‡mm‡g›U Kiæb  wfUvwgb we1 w`b (_vqvwgb) 100 wgMÖv/cÖwZw`b 5 w`b|  Kx Kx cywói Afve Av‡Q Zv Lyu‡R †ei Kiæb 3. nvB‡Wªmb eRvq ivLv  nvB‡Wªmb ïiæ Kiv hw` m¤¢e nq  cÖPzi cvwb/ Zij cvb Kivi e¨vcv‡i DrmvwnZ Kiæb (me©wb¤œ 2-3 wjUvi cÖwZw`b)| 4. hLb Rxeb SuywK‡Z co‡e Ggb cÖZ¨vnv‡ii jÿYmg~n Avi _vK‡ebv Zvici G‡mm‡g›U Ges †g‡bR‡g›U Ki‡Z n‡e g` I gv`‡Ki ÿwZKi e¨env‡ii (g~j evZ©v †`Lyb GB gwWDj Gi) †UwejSUB1: Rxeb SzuwK‡Z _vKv g` cÖZ¨vnv‡ii jÿ‡Y Wvqv‡Rcvg cÖ‡qvM Diazepama Zvr¶wbK cÖ`vb 10-20 wg.MÖv. m‡e ©v”P 4 evi/w`‡b 3-7 w`b cieZ©x †WvR j¶Y K‡g †M‡j ª`æZ †WvR/ev cwigvY Kwg‡q †dj‡Z n‡e| †ivMx‡K wbqwgZ bR‡i ivL‡Z n‡e, †Kbbv Jly‡a wewfbœ R‡bi wewfbœ ai‡bi cÖwZwµqv nq। †Wv‡Ri c_ gyL Zxeª cvk¦-cÖwZwµqv (Lye Kg) k¦vmcªk¦vm †b‡g Avmv*, ¸iæZi †PZbvMZ mgm¨v mveavbZvt k¦vm cÖk¦vm gwbUi Ki‡Z n‡e, Ges D‡ËRbvi gvÎv evi evi cixÿv Ki‡Z n‡e mvaviY cvk¦©cÖwZwµqv Z›`ªv fve, fz‡j hvIqv, m‡PZbZvq cwieZ©b, gvsm‡cwki ~`e©jZv mveavbZvt hw` Z› ª`vfve _v‡K Z‡e cieZ©x †WvR bv †`Iqv we‡kl‡Mvwôi Rb¨ c~e©mZK©Zv cÖ Í¯vweZ †Wv‡Ri g‡a¨ eq¯‹‡`i Rb¨ GK PZz_©vsk A_ev A‡a©K, k¦vm- cÖk¦v‡mi mgm¨v _vK‡j e¨envi Ki‡eb bv †Wwjwiqvg hw` g` †Q‡o †`Iqvi d‡j nq e‡j g‡b nq Z‡e Rxeb SuywK‡Z Av‡Q Ggb g` cÖZ¨vnv‡ii jÿY †`Lv w`‡j ª`yZ Riæwi e¨e ’¯vcbv cwiKíbv wb‡Z n‡e (wb‡P †`Lyb) Ges KviI mv‡_ Kv‡Qi nvmcvZv‡j cvVv‡bvi e¨e ’¯v Kiv 61 AvZ¥nZ¨v GKRb e¨w³i AvZ¥nZ¨v wKsev wb‡Ri ÿwZi SzuwK‡Z _vKvi Awf‡hv‡Mi mvaviY ˆewk󨸇jv n‡jv Pig nZvk I `y ©`kvMÖ Í¯ _vKv Mfxi nZvk †eva Kiv I gb Lvivc _vKv AZx‡Z wb‡Ri ÿwZi Kivi Rb¨ GKvwaK cÖ‡Póv †bIqvi BwZnvm _vKv (†hgbt wKUbvkK †L‡q †djv, AcwiwgZ gvÎvq Ilya LvIqv, wb‡Ri RLg Kiv) S U I gvbwmK †ivM, Zxeª Av‡eMxq `y` ©kv Ges nZvkv Gme mvaviYZ gvbweK cwiw¯’wZ‡Z †`Lv hvq| GB mgm¨v¸‡jv †h KvD‡K AvZ¥nZ¨v* A_ev AvZ¥nvwb/wb‡R‡K AvNvZ Kiv* nq, Ggb Kv‡Ri w`‡K †V‡j w`‡Z cv‡i| †Kvb †Kvb ¯^v ’¯¨-‡mev Kg©x Av‡Qb, hviv fzj K‡i f‡q _v‡Kb †h AvZ¥nZ¨v wb‡q wRÁvmv Ki‡j e¨w³‡K AvZ¥nZ¨vi w`‡K cÖ‡ivwPZ Ki‡Z cv‡i| Ab¨w`‡K, AvZ¥nZ¨v wb‡q K_v ej‡j e¨w³i AvZ¥NvZx wPšÍvfvebvi mv‡_ RwoZ D‡ØM A‡bKvs‡kB K‡g cvq, e¨w³‡K Zvi mgm¨vi e¨vcv‡i bZzb K‡i eyS‡Z mvnvh¨ K‡i Ges GB mgm¨vwU wb‡q bZzb K‡i Avjvc Kivi my‡hvM ˆZwi nq| GB MvBWwU‡Z Av‡jvPbv n‡q‡Q, †h mKj cÖvßeq¯‹ Ges wK‡kvi wK‡kvixiv gvbwmK, œ¯vqyweK Ges gv`K e¨envi RwbZ mgm¨vq Av‡Qb (GgGbGm) Zv‡`i AvZ¥nZ¨v Ges AvZ¥nvwbi SuywK wb‡q| SUI A¨v‡mm‡g›U cÖkœ 3t e¨w³ wK cvkvcvwk Ggb cwiw¯ ’wZi ga¨ w`‡q hv‡”Qb hv AvZ¥nZ¨v wKsev AvZ¥nvwbi mv‡_ mswkøó? 49 A¨v‡mm‡g›U wba©vi‡Yi Rb¨t  wel cÖ‡qv‡M, g` A_ev gv`‡Ki welwµqv, AcwiwgZ gvÎvq Ilya †L‡q A_ev Ab¨ †Kvb Dcv‡q wb‡Ri ÿwZ Kiv  †h mKj j¶‡Y ª`æZ wPwKrmv cÖ‡qvM Kiv cÖ‡qvRb  wb‡R‡K Ggb fv‡e RLg Kiv †hb i³cvZ nq|  †PZbv nvwi‡q †djv।  Pig K¬vwšÍ ev RoZv| S U I » m¤¢ve¨ KviY¸‡jv LyuRyb Ges Zv wbqš¿Y Kivi e¨e¯’v wbbt ◆ mvB‡Kvwmm (>> PSY) ◆ `xN© mgq a‡i e¨v_v A_ev A¶gZv (†hgbt Aí w`b Av‡Mi ¶wZ hv Riæwi Ae¯’vi mg‡q N‡U‡Q) ◆ ¶wZKi A¨vj‡Kvnj A_ev gv`‡Ki e¨envi (>> SUB) ◆ gvSvwi-¸iæZi welYœZv †ivM (>> DEP) ◆ †cv÷-UªgvwUK †÷ªm wWmAW©vi (>> PTSD) ◆ GwKDU B‡gvkbvj wWm‡Uªm (>> ACU, GRI, OTH). Box SUI 1: wKfv‡e AvZ¥nZ¨v A_ev wb‡Ri ÿwZ wb‡q K_v ej‡eb 1.GKwU wbivc` Ges GKvšÍ cwi‡ek ˆZwi Kiæb hv‡Z e¨vw³ Zvi wPšÍvfvebv ¸‡jv ej‡Z cv‡i » AvZ¥nZ¨vcÖeY nIqv Rb¨ e¨w³wU fv‡jv wK g›` †mfv‡e wePvi Ki‡eb bv » e¨w³‡K Zvi cQ›` g‡Zv GKv A_ev Ab¨‡Kmn †h Zvi cQ‡›`i †m gvbylmn K_v ejvi cÖ¯Íve w`b 2. Ggb wKQz ¯^vfvweK cÖkœ e¨envi Kiæb hvi Dˇi K_vi wc‡V mn‡RB Av‡iKwU cÖkœ Kqv hvq | †hgbt » [eZ©gvb Ae¯’v w`‡q ïiæ Kiæb] Avcwb GLb †Kgb †eva Ki‡Qb? » [e¨vw³i Abyf‚wZ‡K we‡ePbv Kiæb] Avcbv‡K †`L‡Z nZvk †`Lv‡”Q/ wegl© jvM‡Q| Avwg Avcbv‡K G wel‡q wKQz cÖkœ Ki‡Z PvB| » Avcbvi fwel¨Z Avcwb †Kgb †`‡Lb? mvg‡bi w`b¸‡jv‡Z Avcwb Kx Kx Avkv K‡ib? » Avcbvi g‡ZvB mgm¨vq †fvMv wKQz gvbyl Avgv‡K e‡jwQ‡jvZviv Abyfe K‡iwQ‡jb RxebUv G‡Zv KóKi bq? KLbI Nygv‡bvi Av‡M Ggb g‡b K‡ib †h Kvj Nyg †_‡K bv DV‡jB nqZ fv‡jv? » Avcbvi wK wb‡R‡K AvNvZ Kivi wPšÍv gv_vq Av‡m? » Avcwb wK wb‡Ri Rxeb †kl K‡i †`Iqvi †Kvb cwiKíbv Ki‡Qb? » hw` ZvB nq, wKfv‡e Avcwb Zv cwiKíbv K‡i‡Qb? »Rxeb †kl Kivi Rb¨ Avcbvi Kv‡Q wK ai‡bi hš¿cvwZ Av‡Q? »Avcwb KLb KvRwU Ki‡eb Zv wK †f‡e‡Qb? »Avcwb wK KLbI Gi Av‡M AvZ¥nZ¨v Kivi †Póv K‡i‡Qb? 3. hw` e¨w³ AvZ¥nZ¨v Ki‡Z Pvq GgbwU Rvbvqt » GKUv kvšÍ Ges mnvqK AvPiY eRvq ivLyb » wg_¨v cÖwZkÖæwZ w`‡eb bv| A¨v‡mm‡g›U cÖkœ 1: e¨w³ wK m¤cÖwZ AvZ¥nZ¨v wKsev wb‡Ri ÿwZ Kivi †Póv K‡i‡Qb? A¨v‡mm‡g›U cÖkœ 2: e¨w³i wK AvZ¥nZ¨v wKsev AvZ¥nvwbi Avmbœ †Kvb SuywK Av‡Q?  e¨w³ A_ev Zvi ZË¡veavqK †K wR‡Ám Kiæbt » e¨w³i gv‡S Avmbœ AvZ¥nZ¨v ev AvZ¥nvbi SuywK Av‡Q e‡j  AvZ¥nZ¨v Kivi K_v fve‡Qb wKsev cwiKíbv Ki‡Qb wKbv (eZ©gvb wKsev †kl gv‡m) we‡ePbv Kiv n‡e hw` wb‡Pi †Kvb welq eZ ©gv‡b Dcw ’¯Z _v‡Kt  Av‡Mi eQ‡i AvZ¥nvwb ev wb‡Ri ÿwZ Kivi aib » AvZ¥nZ¨vi wPšÍv, cwiKíbv ev cÖwµqveZ©gvb _vKv  AvZ¥nZ¨v Kivi wRwbmcÎ Zvi Av‡k cv‡k Av‡Q wKbv » MZgv‡mi BwZnv‡m AvZ¥nvwbi wPšÍv ev cwiKíbv _vKv ( †hgbt wKUbvkK, `wo, A ¿¯, PvKz, JlyacÎ Ges WªvM BZ¨vw`) MZeQ‡i wb‡Ri ÿwZi ai‡bi BwZnvm _vKv Ggb GKRb e¨w³ whwb GLb Pig Aw ’¯i, mwnsm, wbivk ev K_v ej‡Q bv Ggb » Luy‡R †`Lybt  cÖPÛ Av‡eMxq msKUve ’¯v A_ev Avkv nvwi‡q †djv  wns ª¯ AvPiY A_ev AwZwi³ DrKÉv  K_v ejv wKsev †hvMv‡hvM Kivi B”Qv nvwi‡q †djv wKsev eÜ Kiv »wb‡æv³ welq¸wj Dcw¯’Z _vK‡j e¨w³ AvÍnZ¨v wKsev AvÍ Awbó Kivi SzuwK‡Z Av‡Qb| ◆◆eZ©gvb wPš—v, AvÍnZ¨v Kivi cwiKíbv wKsev †Póv Ki‡Qb Ggb ◆◆ wb‡Ri ¶wZ Kiv wKsev AvÍnZ¨v Kivi AZxZ †iKW© Av‡Q Ggb e¨w³ hw` Avevi AwaK gvÎvq DMÖ AvPiY Ki‡Qb, gvbwmK hš¿bv †fvM Ki‡Qb Ges mK‡ji mv‡_ †hvMv‡hvM Kwg‡q †d‡j‡Qb 63 g~j wPwKrmv cwiKíbv 1. hw` e¨w³ AvZ¥nZ¨v Kivi †Póv K‡i, Zv‡K cÖ‡qvRbxq ch©‡e¶‡Y ivLyb, wPwKrmv †mev cÖ`vb Kiæb Ges g‡bvmvgvwRK mnvqZv w`b| » wPwKrmv †mev cÖ`vb Kiæbt ◆ hviv wb‡R‡`i RLg wKsev ¶wZ Kivi †Póv K‡i‡Q Zv‡`i Ab¨‡`i gZB mgvb mvnvh¨,m¤§vb I gh©v`v Ges cÖvB‡fwm w`b| Zv‡`i kvw¯Í w`‡eb bv| ◆ ¶Z A_ev welwµqvi wPwKrmv Kiæb| ▸ wKUbvk‡Ki welwµqvi Rb¨, Clinical Management of Acute Pesticide Intoxication (WHO, 2008)†`Lyb| ◆ †ivMx e¨e¯’vc‡Îi AcwiwgZ Jlya †L‡q †d‡j hv GLbI Zvi Rb¨ cÖ‡qvRbxq, Z‡e †ivMx‡K Kg cvk¦© cÖwZwµqvm¤cbœ Ilya w`b| m¤¢e n‡j, †ivMx‡K bZzb &Jla w`b wKQz mg‡qi Rb¨ ( †hgbt GKevi wKQz w`b n‡Z GK mßvn ch ©šÍ) Avevi hv‡Z †m AwZwi³ Jla †meb bv Ki‡Z cv‡i| » hviv mvg‡b AvZ¥nZ¨v Kivi SzuwK‡Z Av‡Qb Zv‡`i µgvMZ mZK©Zvi mv‡_ bR‡i ivLyb (MvBWjvB‡bi Rb¨ wb‡P †`Lyb) » g‡bvmvgvwRK mnvqZvi cÖ¯Íve w`b (MvBWjvB‡bi Rb¨ wb‡P †`Lyb) » m¤¢e n‡j GKRb gvbwmK ¯^v¯’¨ we‡kl‡Ái mv‡_ civgk© wbb| 2. e¨w³ hw` Awbevh© AvZ¥nZ¨v A_ev wb‡Ri ÿwZ Ki‡e Ggb SzuwK‡Z _v‡K, Z‡e ch©‡eÿY Kiæb Ges g‡bvmvgvwRK mnvqZv w`b » e¨w³‡K ch©‡eÿY ivLybt  †m e¨w³wUi Rb¨ GKwU wbivc` Ges AbyK‚j cwi‡ek ˆZwi Kiæb| AvZ¥nZ¨v/ wb‡Ri ¶wZ Ki‡Z cv‡i Ggb e¯‘ †_‡K e¨w³‡K ~`‡i ivLyb, m¤¢e n‡j Zv‡K GKwU kvšÍ I Avjv`v iæ‡gi e¨e¯’v Kiæb| hvB †nvK, e¨w³wU‡K GKv ivL‡eb bv| me mgq KvD‡K Kv‡Q ivLyb, whwb e¨w³‡K †`Lvïbv Ki‡Z I Zv‡K mnvqZv w`‡Z cv‡i|  AvZ¥nZ¨v cÖwZ‡iva Ki‡Z e¨w³‡K †Rbv‡ij nvmcvZv‡ji †ivMxi g‡Zv iæwUb †PK Avc Gi ¯’v‡b fwZ © Ki‡eb bv| nvmcvZv‡ji ÷vdiv ch©vß cwigvY mgq e¨w³‡K bvI w`‡Z mÿg n‡Z cv‡i| hw` AvZ¥nZ¨v B”QzK e¨w³‡K wb‡R‡K RLg wKsev Ab¨vb¨ Kvi‡Y cÖ‡qvR‡b nvmcvZv‡ji †Rbv‡ij Iqv‡W © fwZ© Ki‡ZB nq, Z‡e mve©¶wYK †`Lfvj Ki‡Z n‡e hv‡Z nvmcvZv‡j cieZ©x AvZ¥nvwb/wb‡R‡K AvNv‡Zi †Póv Ki‡Z bv cv‡i|  hZ¶Y bv e¨w³i AvZ¥nZ¨vi SzuwK cy‡ivcywi P‡j hv‡e, ZZ¶b ch©šÍ e¨w³ †h RvqMv‡ZB _vKzK Zv‡K PweŸk N›Uv †`Lfvj Kiv‡Z n‡e| » g‡bvmvgvwRK mnvqZv w`b:  e¨w³i Rxe‡bi m¤¢ve¨ mgvavb †`Iqvi †Póv Ki‡eb bv| eis Zvi Avkv RvMv‡bvi †Póv Kiæb| †hgbt ▸ A‡bK gvbylB Ggb cwiw¯’wZ‡Z wQ‡jv- - †f‡ewQ‡jv †Kvb Avkv †bB, g‡i hvIqvB fv‡jv g‡b K‡iwQ‡jv| wKš‘ Zviv †kl ch©šÍ Rxe‡bi Avkv Lyu‡R †c‡q‡Q| Zv‡`i GB fv‡jv Abyf‚wZ mg‡qi mv‡_ mv‡_ AviI †cv³ n‡q‡Q n‡q‡Q|  †eu‡P_vKvi D‡Ïk¨ Zv‡K Lyu‡R †ei Ki‡Z mvnvh¨ Kiæb|  Zvi Rxe‡bi mgm¨vi mgvavb GKmv‡_ LyuR yb|  e¨w³ GB mg‡q AvZ¥nZ¨vi SzuwK‡Z _vK‡j Zvi cwiPh ©vKvix, cwiwPZ mKj eÜy evÜe, wek¦¯Í e¨w³ Ges KwgDwbwUi mvg_©¨ ‡K ch©‡eÿY Ges mnvqZv Ki‡Z ejyb Zv‡`i‡K Kv‡R jvMvb| Zv‡`i †evSvb †h AvZ¥nZ¨v Ki‡Z B”QzK e¨w³i 24 N›Uv †`Lfvj I ZË¡veav‡bi cÖ‡qvRb| Zviv †h‡bv GKUv Kvh©Ki I ev¯Íe cwiKíbv wb‡q KvR K‡i †mw`‡K bRi ivLyb ( †hgbt †K w`‡bi †Kvb mgq †`Lfvj Ki‡eb)|  †÷ªm Kgv‡bv Ges †mvk¨vj mv‡cvU© kw³kvjxKiY g~jbxwZ Abyhvqx Ab¨vb¨ cÖ‡qvRbxq g‡bvmvgvwRK mnvqZv cÖ`vb Kiæb (>> General Principles of Care)| ▸ m¤¢e n‡j gvbwmK ¯^v¯’¨ we‡kl‡Ái mv‡_ civgk© Kiæb| » d‡jvAv‡ci GKwU Kvh©Ki cwiKíbv wbwðZ Kiæb hv‡Z mvnvh¨ cÖ`vbKvixiv wbwðZ d‡jvAv‡ci `vwqZ¡ wb‡Z cv‡i| (>> Principles of Management inGeneral Principles of Care). » e¨w³i mv‡_ wbqwgZ †hvMv‡hvM ivLyb (D`vniY: †gvevBj †dv‡b, †g‡mR cvwV‡q, evmvq wM‡q)| » ïiæi w`‡K Nb Nb d‡jv Avc Kiæb ( cÖ_g `yB gvm cÖwZ mßv‡n) e¨w³i Ae¯’v DbœwZi mv‡_ mv‡_ d‡jv Avc Kwg‡q †d‡jb| (cÖwZ 2 -4 mßvn ci ci)| » hZw`b AvZ¥nZ¨vi SzuwK Av‡Q, ZZw`b ch©šÍ wbqwgZ d‡jv-Avc Pvwj‡q †h‡Z n‡e| cÖ‡Z¨K †hvMv‡hv‡Mi mgq, e¨w³ AvZ¥nZ¨v wb‡q wK fve‡Q Ges cwiKíbv wK †mUv †R‡b wb‡Z n‡e| S U I 4. wbqwgZ †hvMv‡hvM I d‡jvAvc eRvq ivLyb 3.mvnvh¨ cÖ`vbKvix Kx Kx mnvqZv cÖ` vb Ki‡eb Zv Principles of Reducing Stress andStrengthening Social Support G eY©bv Kiv Av‡Q| (>>General Principles of Care) 65 Ab¨vb¨ ¸iæZ¡c~Y© gvbwmK ¯^v¯’¨ cxov hw`I GB wb‡ ©`wkKvq gvbweK cwiw¯’wZi mv‡_ m¤úK©xZ cÖavb cÖavb gvbwmK, œ¯vqyweK I gv`K`ªe¨ e¨envi (GgGbGm) RwbZ mgm¨v wb‡q Av‡jvPbv Kiv n‡jI G‡Z m¤¢ve¨ me gvbwmK Ae ’¯v wb‡q ejv nqwb, hv GKRb e¨w³i gv‡S †`Lv w`‡Z cv‡i| Kv‡RB, GB gwWD‡ji jÿ¨ n‡jv †hme cÖvßeq¯‹, wK‡kvi-wK‡kvix I wkïiv †hme gvbwmK ¯v^ ’¯¨ cxovq fzM‡Q hv GB wb‡`wk©Kvq AšÍfy©³ nqwb, Zv‡`i gvbwmK mnvqZvi Rb¨ wKQz mvaviY wb‡ ©`kbv †`qv| Ab¨vb¨ gvbwmK ¯v^¯’¨ cxovi g‡a¨ i‡q‡Q: (K) wewfbœ kvixwiK j¶Y, hvi †Kvb kvixwiK KviY †bB (L) †gRvR I AvPi‡Yi cwieZ©b, hv D‡Ø‡Mi KviY n‡jI GB wb‡ ©`wkKvi Ab¨vb¨ gwWD‡j ewY©Z gvbwmK Ae ’¯vi ˆewk‡ó¨i mv‡_ †g‡j bv| Gi g‡a¨ i‡q‡Q g„ y` welYœZvRwbZv †ivM Ges Ab¨vb¨ mvewK¬wbK¨vj Ae ’¯v| Ab¨vb¨ gvbwmK ¯v^¯’¨ cxov‡KI †ek ¸iæZ¡ mnKv‡i †`Lv nq, hLb Gi d‡j e¨w³i ˆ`bw›`b KvR evavMÖ¯’ nq A_ev e¨w³ hLb wb‡R mvnvh¨ PvB‡e| OTH A¨v‡mm‡g›U A¨v‡mm‡g›U cÖkœ 1: Ggb †Kvb kvixwiK KviY Av‡Q wK, hv jÿY¸‡jv‡K cy‡ivcywi e¨vL¨v K‡i? » h_vh_ †gwW‡Kj Bb‡fw÷‡Mk‡bi gva¨‡g GKwU mvaviY kvixwiK cixÿv Pvjvb » kvixwiK KviY mbv³ n‡j Gi e¨e¯’vcbv wbb Ges jÿY¸‡jv GLbI Av‡Q wK-bv, cybivq hvPvB Kiæb| A¨v‡mm‡g›U cÖkœ 2: GUv wK †Kvb GgGbGm Ae ’¯v, hv GB wb‡ ©`wkKvi Ab¨ gwWD‡j Av‡jvwPZ n‡q‡Q? » ev` w`b:  Zxeª gvbwmK Pv‡ci (>> ACU) ¸iæZ¡c~Y© j¶Ymg~n ▸ g~j ˆewkó¨: ∙ MZ GK gv‡mi g‡a¨ m¤¢ve¨ UªgvwUK NUbv ∙ GB NUbvi ci †_‡KB j¶Ymg~‡ni ïiæ ∙ jÿY †_‡K gyw³ †c‡Z mvnvh¨ †LuvRv A_ev jÿYmg~‡ni Kvi‡Y ˆ`bw›`b KvR e¨vnZ nIqv  Zxeª †kv‡Ki (>> GRI) ¸iæZ¡c~Y© jÿYmg~n ▸ g~j ˆewkó¨ : ∙ eo ai‡bi ÿwZi ci †_‡K j¶Y ïiæ ∙ jÿYmg~n †_‡K gyw³ †c‡Z mvnvh¨ †LuvRv ev jÿYmg~‡ni Kvi‡Y ˆ`bw›`b KvR e¨vnZ nIqv  gvSvix-¸iæZi welYœZvRwbZ mgm¨v (>> DEP) ▸ g~j ˆewkó¨ (AšÍZ 2 mßv‡ni Rb¨) ∙ weivgnxb welYœ †gRvR ∙ my®úófv‡e AvMÖn ev KvR K‡g© Avb›` K‡g hvIqv, GgbwK Av‡M hv Dc‡fvM¨ wQj, †m¸‡jv‡ZI ∙ jÿYmg~‡ni Kvi‡Y ˆ`bw›`b Kv‡R †ek mgm¨v nIqv  †cv÷ UªgvwUK †÷ªm wWmAW©vi (>> PTSD) ▸ g~j ˆewkó¨ ∙ GK gv‡miI †ewk mgq Av‡M m¤¢ve¨ UªgvwUK NUbv NUv ∙ µgvMZ f‡qi ¯^cœ †`Lv, Av‡Mi NUbv g‡b cov A_ev Pig fq ev AvZ¼c~Y© AbvûZ ¯§„wZ ∙ B”QvK…Z NUbvi ¯§„wZ Gov‡bv ∙ eZ©gvb ûgwKi e¨vcv‡i Abyf‚wZ e„w× (wec‡` AwZwi³ D‡ØM I mZK©Zv ev D”P kã ï‡b k³ cÖwZwµqv ev AbvKvw•ÿZ bovPov) ∙ j¶Ymg~‡ni Kvi‡Y ˆ`bw›`b KvRKg© †ek mgm¨v nIqv  ÿwZKi g` ev gv`K MÖnY (>> SUB) ▸ g~j ˆewkó¨ ∙ Ggb g` I gv`K MÖnY Kiv hv wb‡Ri I/ev A‡b¨i ÿwZi KviY  AvZ¥nZ¨v / wb‡Ri ÿwZ Kiv (>> SUI) ▸ g~j ˆewkó¨ ∙ wb‡Ri ÿwZi eZ©gvb KvR; AvZ¥nZ¨vi eZ©gvb wPšÍv I cwiKíbv A_ev ∙ GKRb e¨w³i g‡a¨ wb‡Ri ÿwZ Kivi wPšÍv, cwiKíbv ev KvRKjvc, whwb ¸iæZi nZvkvMÖ¯’, D‡ËwRZ, †hvMv‡hv‡M Awb”QzK ev gv`K †bqv eÜ K‡i‡Qb » hw` Dc‡ii †Kvb GKwU Ae ’¯v m‡›`n nq, Z‡e A¨v‡mm‡g›U Ki‡Z I e¨e ’¯v wb‡Z h_vh_ gwWD‡j hvb » hw` 1) kvixwiK KviY ev` †`qv nq, 2) Dc‡ii MNS Ae ’¯v e¨w³i bv _v‡K Ges 3) †mB e¨w³ hw` Zvi j¶Ymg~n †_‡K gyw³ †c‡Z mvnvh¨ †Luv‡R ev j¶Y¸‡jv ˆ`bw›`b Kv‡R weNœ NUvq, Z‡e †mB e¨w³i Ab¨ †Kvb ¸iæZ¡c~Y© gvbwmK ¯^v¯’¨ cxov Av‡Q|  mvaviYZ kvixwiK KviY I Dc‡ii MNS Ae ’¯v ev` w`‡Z GKvwaK mv¶vZKv‡ii cÖ‡qvRb nq| A¨v‡mm‡g›U cÖkœ 3: hw` e¨w³ eqtmwÜÿ‡Yi nq, Z‡e Zvi wK †Kvb AvPiYMZ mgm¨v Av‡Q? » AvPiYMZ mgm¨v gvÎv hvPvB Ki‡Z eqtmwÜÿ‡Y _vKv e¨w³ I Zvi hZœKvix Df‡qi mvÿvZKvi wbb: †hgb:  cÖv_wgK mwnsmZv  gv`K †bqv  eywjs ev mgeqmx‡`i cÖwZ wbg©g nIqv  aŸsmvZ¥K AvPiY  SuywKc~Y© †hŠb AvPiY » hw` eqtmwÜÿ‡Y _vKv e¨w³i AvPiYMZ mgm¨v _v‡K, Z‡e Av‡iv cÖkœ Kiæb:  eqtmwÜÿ‡Y _vKv e¨w³i AZx‡Z ev eZ©gv‡b cÖPÐ gvbwmK Pvc (†hgb: †hŠb wbh©vZb)  evev-gv welqK (Am½wZc~Y© I K‡Vvi wbqg-k„•Ljv, mxwgZ Av‡eMxq mg_©b, mxwgZ ch©‡eÿY Ges hZœKvixi gvbwmK Ae¯’v  eqtmwÜÿ‡Y _vKv e¨w³ Zvi AwaKvsk mgq wKfv‡e KvUvq| wR‡Ám Kiæb: ▸ (eqtmwÜÿ‡Yi e¨w³ hw` KvR K‡i ev ¯‹y‡j hvq) Zzwg †Zvgvi KvR/¯‹zj †k‡l wKfv‡e mgq KvUvI? †Kvb wbqwgZ KvR Av‡Q wK, hv Zzwg Ki? ▸ Zzwg wK cÖvqB wei³ nI? wei³ jvM‡j Zzwg wK Ki? g~j wPwKrmv cwiKíbv 67 ÒAb¨vb¨ ¸iæZ¡c~Y© gvbwmK ¯^v¯’¨ cxovÓi Rb¨ †Kvb Ilya †`Iqv hv‡e bv (we‡kl‡Ái civgk© Qvov)| wfUvwgb Bb‡RKkb ev Ab¨ †Kvb AKvh©Ki Ilya w`‡e bv| AdjcÖmy wPwKrmv Kivi †Póv Ki‡eb bv 1. me †¶‡Î (e¨w³i Av‡eMxq, kvixwiK ev AvPiYMZ mgm¨v, †hUvB †nvK) g‡bvmvgvwRK mnqZv w`b, †hfv‡e gvbwmK Pvc Kgv‡bv I mvgvwRK mnvqZv evov‡bvi bxwZ‡Z ewY©Z (>> †mevi mvaviY g~jbxwZ) » eZ©gvb g‡bvmvgvwRK Pvc †gvKv‡ejv » mvgvwRK mnvqZv e„w× » gvbwmK Pvc e¨e ’¯vcbv †kLv‡bv 2. hw` †Kvb kvixwiK KviY wPwýZ bv nq, †hUv eZ©gvb †mvgvwUK/kvixwiK jÿY‡K cy‡ivcywi e¨vL¨v K‡i, Z‡e jÿY¸‡jv ev ͯeZv ¯x^Kvi Kiæb Ges m¤¢ve¨ e¨vL¨v w`b » cwi®‹vi †gwW‡Kj Bw½Z bv _vK‡j Avi †Kvb j¨ve‡iUwi ev Ab¨vb¨ cixÿvi wb‡ ©`k †`‡eb bv (†hgb, eo †Kvb A¯^vfvweK j¶Y)|  evi evi AcÖ‡qvRbxq †gwW‡Kj Bb‡fw÷‡Mkb e¨w³i g‡b aviYv Rb¥v‡Z cv‡i †h, Zvi kvixwiK mgm¨v n‡q‡Q|  wK¬wbK¨vj Bb‡fw÷‡Mk‡bi wecixZ cvk¦©cÖwZwµqv _vK‡Z cv‡i| » †ivMx‡K Rvbvb †h, Zvi ¸iæZi †Kvb AmyL aiv c‡owb| wK¬wbK¨vj I †U‡÷ cvIqv mvaviY welq¸‡jv Rvbvb|  Avgiv ¸iæZi †Kvb mgm¨v cvBwb| G Ae ’¯vq Av‡iv †Kvb cixÿvi cÖ‡qvRb Av‡Q e‡j Avgvi g‡b nq bv| » hw` e¨w³ AveviI †U÷ Ki‡Z †Rvi K‡i, Z‡e ej‡Z cv‡ib:  AcÖ‡qvRbxq cixÿv Kiv ¶wZKviK n‡Z cv‡i KviY Gi d‡j LvgLv y`wðšÍv I cvk¦©cÖwZwµqv †`‡e| » ¯^xKvi K‡i †bIqv †h j¶Y¸‡jv KvíwbK bq, eis jÿY¸‡jvi mgvavb GLbI ¸iæZ¡c~Y©, hv h‡_ó y`k©bvi KviY| » GB j¶Y¸‡jvi KviY m¤ú‡K© e¨w³i wb‡Ri e¨vL¨v Rvb‡Z Pvb| hv KviY wb‡q aviYv w`‡Z cv‡i, e¨w³i mv‡_ Av ’¯vi m¤úK© Mo‡Z mvnvh¨ Ki‡Z cv‡i Ges e¨e¯’vcbvi cÖwZ e¨w³i wek¦¯ÍZv evo‡e| » Av‡eMxq hš¿Yv/gvbwmK Pv‡ci e¨vL¨vq kvixwiK ms‡e`bkxjZvi AwfÁZvI D‡V Avm‡Z cv‡i (†cU e¨v_v, †ckxi D‡ËRbv BZ¨vw`)| e¨w³i Av‡eM/gvbwmK Pvc Ges jÿY¸‡jvi g‡a¨ m¤¢ve¨ †hvMm~Î Rvb‡Z Pvb I Av‡jvPbv Kiæb| » ˆ`bw›`b KvRKg© Pvwj‡q †h‡Z (A_ev ax‡i ax‡i Kv‡R wdi‡Z) DrmvwnZ Kiæb| » gvbwmK Pvc Kgv‡bv I g‡bvmvgvwRK mnvqZv e„w×i bxwZgvjv cÖ‡qv‡Mi K_vI g‡b ivLyb| (>> †mevi mvaviY g~jbxwZ) 3. e¨w³ hw` eqtmwÜKv‡ji n‡q _v‡K, hvi AvPiYMZ mgm¨v Av‡Q » eqtmwÜ e¨w³i Kv‡Q mgm¨v wb‡q Zvi wb‡Ri aviYv ïb‡Z mgq wbb (hZœKvixi Dcw ’¯wZ Qvov Ki‡Z cvi‡j fvj) » eqtmwÜ e¨w³ I Zvi hZœKvix‡K mvB‡KvGWz‡Kkb w`b| wb‡Pi e¨vL¨v w`b:  eqtmwÜKv‡j ÿzä, wei³, D‡ØM ev `yt‡L A‡bK mgq Zv‡`i g‡a¨ mgm¨vc~Y© AvPiY ˆZwi nq| Ggb AvPiY m‡Z¡I Zv‡`i wbqwgZ hZœ I mn‡hvwMZv cÖ‡qvRb|  KwVb n‡jI eqtmwÜ e¨w³i mv‡_ hZœKvixi †hvMv‡hvM iÿvi †Póv K‡i †h‡Z n‡e|  hZœKvixi Rb¨ we‡kl evZ©v: ▸ BwZevPK, Dc‡fvM¨ KvR Lyu‡R †ei Kiæb, †hUv Avcbviv GKmv‡_ Ki‡Z cv‡ib| ▸ eqtmwÜ e¨w³‡K wK Ki‡Z †`‡eb Ges wK Ki‡Z †`‡eb bv, †m e¨vcv‡i m¤§v‡bi mv‡_ c~e©vci GKB iKg _vKzb| ▸ eqtmwÜ e¨w³‡K fv‡jv Kv‡Ri cyi¯‹vi w`b ev cÖksmv Kiæb, †h AvPiY ¸iæZi mgm¨vi, †Kej †m¸‡jvB ïa‡i w`b| ▸ KLbB kvixwiK kvw ͯ w`‡eb bv| g›` Kv‡R kvwšÍi †P‡q fv‡jv Kv‡Ri cÖksmv †ewk Kiæb| ▸ Avcwb hLb Lye nZvk _v‡Kb, ZLb Zvi mv‡_ weZÐvq Rov‡eb bv| kvšÍ bv nIqv ch©šÍ A‡cÿv Kiæb|  wbw`©ó welqe¯‘ wb‡q Zvi mv‡_ Av‡jvPbv Kiæb| ▸ GK‡Nu‡qwg, gvbwmK Pvc ev ivM †gvev‡ejvi A‡bK ¯^v ’¯¨ m¤§Z Dcvq Av‡Q (†hgb, †h mKj KvR Avgv‡`i wkw_j K‡i, †m¸wj Kiv, kvixwiKfv‡e mwµq _vKv, KwgDwbwUi Kvh©µ‡g hy³ _vKv)| ▸ wek¦¯Í Kv‡iv Kv‡Q wb‡Ri ivM, wei³, D‡ØM ev y`tL wb‡q K_v ej‡j DcKvi n‡Z cv‡i| ▸ g` ev Ab¨vb¨ gv`K ivM I welYœ †eva‡K Av‡iv Lviv‡ci w`‡K wb‡q †h‡Z cv‡i Ges G¸‡jv Gwo‡q Pjv DwPZ| » AskMÖnY evovb:  AvbyôvwbK I AbvbyôvwbK wk¶vq  mywbw`©ó, D‡Ïk¨c~Y©, mvaviY ¯^v‡_©i Kg©Kv‡Ð (†hgb, AvkÖq ˆZwi)  MVbg~jK †Ljvi Kg©m~wP » eqtmwÜ e¨w³ I Zv‡`i hZœKvix MÖæ‡ci gvbwmK Pvc Kgv‡bv I g‡bvmvgvwRK mnvqZv e„w×i bxwZgvjv cÖ‡qv‡Mi K_vI g‡b ivLyb| (>> †mevi mvaviY g~jbxwZ) 4. d‡jv-Avc » jÿYmg~n Ae¨vnZ _vK‡j, Lviv‡ci w`‡K †M‡j ev Amn¨ n‡q DV‡j wd‡i Avmvi civgk© w`b| » hw` †Kvb DbœwZ †`Lv bv hvq A_ev e¨w³ ev hZœKvix Av‡iv cixÿv-wbixÿvi Rb¨ Pvc †`q, Z‡e GKRb we‡kl‡Ái civgk© wbb| Annex 1: UNHCR (2014) Health Information System (HIS) Case Definitions (UNHCR (2014) ¯^v¯’¨ Z_¨ c×wZ (HIS) NUbvi weeiY) 1. Gwc‡jcwm/wLuPzbx Gwc‡jcwm AvµvšÍ e¨w³i AšÍZ 2 Gwc‡mv‡Wi wLuPzbx _v‡K, hv R¡i, msµgY, AvNvZ ev A¨vj‡Kvnj cÖZ¨vnv‡ii g‡Zv `„k¨gvb †Kvb Kvi‡Y nq bv| GB Gwc‡mvW¸‡jv‡Z †PZbv nviv‡bvi mv‡_ mv‡_ A½cÖZ¨‡½ Kuvcywb Ges KLbI KLbI kvixwiK AvNvZ, cÖ¯ ªve-cvqLvbv wbqš¿‡Y ivL‡Z bv cviv I wRf Kvgov‡bvi mv‡_ _vK‡Z cv‡i| 2. A¨vj‡Kvnj ev Ab¨vb¨ †bkv ª`e¨ e¨envi msµvšÍ †ivM GB †iv‡M AvµvšÍ e¨w³ A¨vj‡Kvnj ev Ab¨vb¨ †bkv ª`e¨ †bqvi †Póv K‡i Ges Zv MÖn‡Yi cwigvY wbqš¿Y Ki‡Z mgm¨vq c‡o| cÖvqB e¨w³MZ m¤úK©, Kg© `ÿZv I kvixwiK ¯^v‡ ’¯¨i AebwZ nq| G me mgm¨v m‡Ë¡I e¨w³ A¨vj‡Kvnj ev Ab¨vb¨ †bkv ª`e¨ wb‡Z _v‡K| 3. eyw× cÖwZewÜZv Lye Kg eyw× _vKv ˆ`bw›`b Kv‡R mgm¨vi KviY| eyw×gËv Ggb nq hv ˆ`bw›`b Rxe‡b mgm¨vi m„wó K‡i| G‡ÿ‡Î wkïiv †`wi K‡i K_v ej‡Z †k‡L| cÖvßeq¯‹iv †Kej mnR KvR m¤cbœ Ki‡Z cv‡i| GB e¨w³ K`vwPr ¯^vaxbfv‡e Pj‡Z ev wb‡R‡K †`Lfvj Ki‡Z cv‡i Ges/ev A‡b¨i mvnv‡h¨i Ici wbf©ikxj n‡q _vK‡Z cv‡i| hLb GB AÿgZv ¸iæZi nq, ZLb e¨w³i K_v ej‡Z Ges Ab¨‡K eyS‡Z mgm¨v nq Ges µgvMZ mvnv‡h¨i cÖ‡qvRb nq| 4. mvB‡KvwUK †ivM (g¨vwbqv mn) Ggb wKQz †kvbv ev †`Lv, hvi Aw¯ÍZ¡ †bB A_ev k³fv‡e wek¦vm Kiv, hv mZ¨ bq| Zviv wb‡Ri mv‡_ K_v e‡j, hv weåvwšÍKi I AmsjMœ Ges Zv‡`i gyLveqe A¯^vfvweK g‡b n‡Z cv‡i| Zviv wb‡R‡`i cÖwZ Ag‡bv‡hvMx| wecixZfv‡e, Zviv KLbI KLbI Ggb mgqI cvi K‡i, hLb Zviv Pig Lywk, wLUwL‡U, D`¨gx, euvPvj I AmshZ _v‡K| GKB ms¯‹…wZi Ab¨vb¨ gvby‡li Kv‡Q IB e¨w³i AvPiY ÔcvMjv‡UÕ ev D™¢U g‡b nq| GB ai‡bi †iv‡Mi g‡a¨ GwKDU mvB‡Kvwmm, µwbK mvB‡Kvwmm, g¨vwbqv I wWwjwiqvg AšÍfz©³| 5. gvSvwi-¸iæZi Av‡eMxq †ivM/welYœZv 2 mßv‡ni †ewk mgq a‡i ˆ`bw›`b Kvh©µg my¯úófv‡e e¨vnZ n‡j Ges Gi KviY K) wegl©/D`vmxbZvq Av”Qbœ Ges/A_ev L) AwZiwÄZ, wbqš¿‡Yi A‡hvM¨ D‡ØM/fq nq| mvaviYZ e¨w³MZ m¤úK©, ÿzav, Nyg I g‡bv‡hvM ¶wZMÖ¯ Í nq| e¨w³ ¸iæZi Aemv` I mvgvwRKfv‡e wb‡R‡K ¸wU‡q †bqvi Awf‡hvM Ki‡Z cv‡ib Ges w`‡bi AwaKvsk mgq weQvbvq KvwU‡q †`b| AvZ¥nZ¨vi wPšÍvI Ki‡Z cv‡ib| GB ai‡bi †iv‡Mi g‡a¨ i‡q‡Q gvbyl‡K Aÿg K‡i †`qvi g‡Zv wW‡cÖkb, D‡ØMRwbZ †ivM Ges †cv÷ UªgvwUK gvbwmK PvcRwbZ †ivM (cybtAwfÁZv, Gwo‡q Pjv I AwaK D‡ËRbvi ˆewkó¨)| GB e¨vwa¸‡jvi g„`y iƒc ÒAb¨vb¨ gvbwmK cxovÓ wn‡m‡e †kªYxfz³ Kiv nq| 6. Ab¨vb¨ gvbwmK cxov GB ai‡bi †iv‡Mi g‡a¨ Av‡eM (†hgb, welYœ gb, D‡ØM), wPšÍv (†hgb, †ivgš’b, `ye©j g‡bv‡hvM) A_ev AvPiY (†hgb, wb®ŒxqZv, AvMÖvmb, Gov‡bv) m¤cwK©Z cxov AšÍfz©³| w`‡bi AwaKvsk ¯^vfvweK KvR-K‡g© mÿgZv _vK‡Z cv‡i, ¯^vfvweK KvR-Kg©| GB cxovi DcmM© wn‡m‡e Kg ¸iæZi Av‡eMRwbZ e¨vwa (†hgb, g„`y welYœZv, D‡ØM ev UªgvwUK NUbv cieZ©x gvbwmK PvcRwbZ †ivM) A_ev mvaviY y``©kv Dc ’¯vcb Ki‡Z cv‡i (†hgb, †Kvb Amy¯’Zv †bB)| AšÍf‚©w³i gvb`Ð: GB †kÖwY‡Z AšÍfz©³ n‡e, K) e¨w³ hw` Dcm‡M©i Kvi‡Y mvnvh¨ cÖv_©bv K‡i Ges L) e¨w³i hw` Dc‡ii 5wUi †KvbwUB bv _v‡K| 7. ¯^v ’¯¨ cixÿvq aiv bv cov kvixwiK Awf‡hvM GB †kÖYx‡Z i‡q‡Q †h †Kvb †mvgvwUK/kvixwiK Awf‡hvM, hvi ˆ`wnK KviY „`k¨gvb bq| AšÍf‚©w³i gvb`Ð: GB †kÖwY‡Z †Kej ZLbB AšÍfy©³ n‡e, hLb K) cÖ‡qvRbxq ¯^v¯’¨ cixÿvi ci, L) e¨w³ Dc‡ii 6 †k ªYxi †KvbwUB hw` bv _v‡K Ges M) e¨w³ hw` Dcm‡M©i Kvi‡Y mvnvh¨ Pvq| 69 Annex 2: Glossary (UxKv)10 11 10 Glossary terms are marked with the asterisk symbol * in the text. 11 The operational definitions included in this glossary are for use only within the scope and context of the publication mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies (WHO & UNHCR, 2015). A¨vmvBwUm (Ascites) wewfbœ Kvi‡Y Zj‡c‡U A¯^vfvweK cvwb Rgv| AvKvw_wmqv (Akathisia) welqMZ A‡_© Aw¯’iZv, mvaviYZt Gi mv‡_ _v‡K AwZwi³ bovPov (†hgb- cv‡qi Aw¯’i wePjb, GK cv †_‡K Ab¨ cv †`vjv‡bv, cvqPvwi, w¯’i nq em‡Z ev `uvwo‡q _vK‡Z A¶gZv)| A¨vgwdUvwgbm& (Amphetamines) GK ¸”Q Ilya, †K› ª`xq ¯œvqyZ‡š¿ †h¸‡jv D‡ËRK cÖfve Av‡Q| G¸‡jv gvbwmK mZK©Zv I †R‡M _vKvi †eva e„w× Ki‡Z cv‡i| wKQz ¯^v¯’¨MZ Ae¯ ’vq †gŠwjK wPwKrmv wn‡m‡e G¸‡jv e¨eüZ n‡Z cv‡i, wKš‘ G¸‡jvi Avevi wKQz AmyweavI i‡q‡Q, †h¸‡jv n¨vjywm‡bkb, welYœZv I KviwWIfvmKzjvi cÖwZwµqvi m„wó Ki‡Z cv‡i| AvPiYMZ mwµqZv (Behavioral Activation) g‡bv‰eÁvwbK wPwKrmv, hv gb Lvivc _vKv m‡Ë¡I Kg©wfwËK I Avb›``vqK Kv‡R RwoZ †i‡L †gRvR Db œxZKi‡Yi w`‡K g‡bv‡hvM †`q| AZzjbxq wPwKrmv c×wZ wn‡m‡e e¨eüZ n‡Z cv‡i, Avevi Ávbxq AvPiYMZ †_ivwci Dcv`vbI n‡Z cv‡i| †eb‡RvWvqv‡RcvBb&m (Benzodiazepines) GK †kªYxi Ilya, hv‡Z D‡ËRbv cÖkgK (Nyg D‡ ª`K K‡i), D‡ØM-we‡ivax (anti-anxiety), A¨vw›UKbfvjm¨v›U (anticonvulsant) Ges †cwk wkw_j Kivi ¸Y i‡q‡Q| evB‡cvjvi wWRAW©vi (Bipolar Disorder) g¨vwbK I wW‡cÖwmf GwW‡mv‡Wi g‡a¨ cwieZ©‡bi ˆewkó¨m¤úbœ ¸iæZi gvbwmK †ivM| †evb g¨v‡iv wW‡cÖkb (Bone Marrow Depression) Aw¯’g¾vi mÿgZv †iva, hv i³ †Kvl Drcv`‡b NvUwZ ˆZwi Ki‡Z cv‡i| K¨vbvwem (Cannabis) MuvRvRvZxq Dw™¢` As‡ki mvaviY bvg, †hUv †_‡K MuvRv, fvs I n¨vk †Zj Drcbœ nq| †auvqv wb‡q †nvK ev LvIqv †nvK, GUv Avb›`RbK Ae¯’v, wkw_jZv Ges Dcjwäi cwieZ©b NUvq| GUv e¨v_v Dckg Ki‡Z cv‡i| ÿwZKi cvk¦©cÖwZwµqvi g‡a¨ i‡q‡Q †cÖlYvi NvUwZ, D‡ËRbv I gw¯Í‡®‹i weK…wZ (c¨vivbqv) †`Lv †`q| gw¯Í‡®‹ cÿvNvZ (Cerebral Palsy) cÖv_wgK weKvkgvb gw¯Í‡®‹ ¯’vqx ¶wZi Kvi‡Y m„ó †cwk mÂvjb I eyw×e„wËK A¶gZvi †ivM| Ávbxq (Cognitive) wPšÍvi mv‡_ m¤cwK©Z gvbwmK cÖwµqv| Gi mv‡_ hyw³, ¯§iY, wm×všÍ, wePvi-we‡kølY, mgm¨vi mgvavb I cwiKíbv AšÍfz©³| KMwbwUf we‡nwfqvi †_ivwc (Cognitive Behavioral Therapy-CBT) g‡bv‰eÁvwbK wPwKrmv, hv Ávbxq Dcv`vbmg~n (wfbœfv‡e wPšÍvi j¶¨, D`vniY¯i^ƒc †bwZevPK wPšÍv‡K wPwýZ I P¨v‡jÄ Kivi gva¨‡g) Ges AvPiYMZ Dcv`vbmg~‡ni (wfb œfv‡e Kivi jÿ¨, D`vniY¯^iƒc GKRb e¨w³‡K Av‡iv cvwZ‡ZvwlK KvR Ki‡Z mvnvh¨ Kivi gva¨‡g) mgš^q| KMwbwUf we‡nwfqvi †_ivwc DB_ Uªgv †dvKvm (Cognitive Behavioral Therapy with Trauma Focus) g‡bv‰eÁvwbK wPwKrmv, hvi wfwË n‡jv- UªgvwUK NUbvq ÿwZMÖ¯Í e¨w³‡`i IB NUbv I Gi cwiYwZ m¤úwK©Z wPšÍv I wek¦vm R‡b¥, hv Zv‡`i †Kvb mvnv‡h¨ Av‡m bv| GB wPšÍv I wek¦v‡mi d‡j H NUbv g‡b Kwi‡q †`q Ggb †Kvb mewKQz‡KB Zviv Gwo‡q P‡j Ges eZ©gvb ûgwKi Abyf‚wZi m„wó K‡i| Gi wPwKrmvq mvaviYZ H me ¯§„wZ‡K Abve„Z Kiv nq Ges Uªgv m¤cwK©Z †h me wPšÍv I wek¦vm, hv †Kvb mvnv‡h¨ Av‡m bv, Zv‡K P¨v‡jÄ Kiv nq| KwgDwbwU wfwËK cybe©vmb (Community Based Rehabilation) gvwë †m‡±vivj †KŠk‡ji gva¨‡g KwgDwbwUi m¤ú` I cÖwZôvb e¨envi K‡i KwgDwbwU‡Z A‡bK wKQzB mieivn Kiv nq| Gi j¶¨ A¶g e¨w³ Ges Zv‡`i cwiev‡ii Rxebgvb DbœZ Kiv, †gŠwjK Pvwn`v †gUv‡bv Ges AšÍf©zw³ I AskMÖnY wbwðZ Kivi gva¨‡g cybe©vmb jvf| †Wwjwiqvg (Delirium) ÿY¯’vqx IVvbvgv K‡i Ggb gvbwmK Ae¯’v, hvi ˆewkó¨ wek„•Lj g‡bv‡hvM (†hgb, mivmwi, wbeÜ, eRvq ivLvi ¶gZv nªvm Ges g‡bv‡hv‡Mi cwieZ©b) Ges m‡PZbZv (cwi‡e‡ki mv‡_ Awf‡hvRb Kivi ¶gZv nªvm), hv msw¶ß mg‡qi g‡a¨ weKvk jvf K‡i Ges w`‡bi g‡a¨ Aw¯’i Ae¯’v Pj‡Z _v‡K| GUv cÖZ¨¶b, ¯§„wZ, wPšÍb, Av‡eM A_ev mvB‡Kv‡gvUi wµqv weNœZvi Abyl½x| Gi Zxeª kvixwiK KviY †hgb, msµgY, †gwW‡Kkb, †gUvewjK A¯^vfvweKZv, †bkvRvZxq c`v_© A_ev Gi cÖZ¨vnvi| wWwjDkb (Delusion) w¯’i wek¦vm, hv cÖvß cÖgv‡Yi wecixZ| †hŠw³i Z‡K©i gva¨‡gI GUv cwiewZ©Z nq bv Ges e¨w³i ms¯‹…wZ I K…wói Ab¨vb¨ †jvKR‡bi Kv‡Q GUv MÖnY‡hvM¨ bq (†hgb, GUv ag©xq wek¦v‡mi welq bq)| wbf©iZv (Dependence) †bkv`ª‡e¨i (WªvM, Gj‡Kvnj, ZvgvK) Dci wbf©ikxjZv, hLb Zviv G¸‡jvi Abycw¯’wZ‡Z Ávbxq, AvPiYMZ I kvixwiK Dcm‡M©i m„wó K‡i| bv wb‡jI wKQz DcmM© ˆZwi nq, hv‡Z Zviv Avev‡iv IB †bkv`ªe¨ wb‡Z Drmvnx nq| Zviv †bkv`ªe¨ e¨env‡i wb‡R‡`i wbqš¿Y Ki‡Z cv‡i bv Ges ¶wZKi cÖfve _vKv m‡Ë¡I Zv Pvwj‡q hvq| WvB‡j‡UW/KÝwUª‡±W wcDwcjm (Dilated/Constricted Pupils) wcDwcj (†Pv‡Li Kv‡jv Ask) n‡jv †Pv‡Li Zvivi ga¨eZ©x cÖviw¤¢K Ask, hv †Pv‡Li g‡a¨ Av‡jv cÖ‡e‡ki cwigvY wbqš¿Y K‡i| wcDwcj mvaviYZ †Pv‡Li wcQbfvM i¶vi Rb¨ Av‡jvi mvg‡b msKzwPZ nq Ges m‡e©v”P Av‡jv †Pv‡Li wfZi cÖ‡e‡ki Rb¨ AÜKv‡i Wvqv‡jU (cÖmviY) NUvq| WvDb wm‡Ûªvg (Down Syndrome) AwZwi³ GKwU †µv‡gvRg 21 Gi Dcw¯’wZi Kvi‡Y ˆRweK Ae¯’v| Bnv wewfbœ gvÎvi eyw×gZvi A¶gZv, axi kvixwiK e„w× Ges gyLvq‡ei ˆewk‡ói mv‡_ m¤cwK©Z| Ilya-†ivM wg_w¯Œqv (Drug-disease Interaction) Ggb Ae¯’v, hv GKB e¨w³i †Kvb GKwU ¯^v¯’¨ mgm¨vi Rb¨ wba©vwiZ Ilya Ab¨ Av‡iKwU ¯^v¯’¨ mgm¨v‡K cÖfvweZ K‡i Ilya-Ilya wg_w¯Œqv (Drug-Drug interaction) hLb GKB e¨w³ `yÕwU Ilya †meb K‡ib Ges y`ÕwU Ilya G‡K Ac‡ii mv‡_ wg_w¯Œqv K‡i Ges GKwU A_ev Df‡qi cÖfve cwiewZ©Z n‡q hvq| wg_w¯Œqvi g‡a¨ i‡q‡Q- †Kvb GKwU Ily‡ai cÖfve K‡g hvIqv, †Kvb GKwU cÖfve ewa©Z Kiv, A_ev welwµqv NUv| G·Uªv wcivwgWvj cvk¦©cÖwZwµqv (Extrapyramidal side-effects) †ckxi bovPovq A¯^vfvweKZv, †hwU †ewki fvM N‡U A¨vw›UmvB‡KvwUK Ilya †me‡bi d‡j| KuvcvKuvwc, k³ n‡q hvIqv, wLuP zwb Ges/A_ev GKv‡_wmqv| AvB gyf‡g›U wW‡mwÝUvB‡Rkb A¨vÛ wi‡cÖv‡mwms (EMDR) gvbwmK AvNv‡Zi d‡j m„ó NUbvi AkÖwgZ ¯§„wZ †_‡K †bwZevPK wPšÍv, Abyf‚wZ Ges AviPY D™¢yZ nq, GB aviYvi Dci wfwË K‡i †`qv gvbwmK wPwKrmv| GB wPwKrmvi g‡a¨ i‡q‡Q Av`k©vwqZ c×wZ, †h¸‡jv GKvav‡i †Rvi †`q: (K) gvbwmK AvNvZ m„wóKvix Qwe, wPšÍv, Av‡e‡Mi mv‡_ kvixwiK Abyf‚wZi ms‡hvM Ges (L) wØcvwÿK DÏxcb †hUv †ewki fvM evisevi †Pv‡Li bvovPvovi gva¨‡g cÖKvwkZ nq| d¬¨vke¨vK (Flashback) GKwU ch©vq hLb GKwU gvbyl Ggbfv‡e wek¦vm K‡ib Ges AvPiY K‡ib †hb Av‡Mi NUbv NUvi mg‡q wd‡i †M‡Qb| d¬¨vke¨vK hv‡`i nq, †mme gvbyl mvgwqKfv‡e mvaviYZ K‡qK †m‡KÛ A_ev wgwb‡Ui Rb¨ ev¯ÍeZvi mv‡_ †hvMv‡hvM nvwi‡q †d‡jb| n¨vjywm‡bkb (Hallucination) GKwU åvšÍ Abyf‚wZ: †Kvb wRwbm †`Lv, †kvbv, Abyfe Kiv, MÜ cvIqv A_ev ¯^v` cvIqv †h¸‡jv ev¯Íe bq| †ncvwUK G‡Ýd¨v‡jvc¨vw_ (Heptic Encephalopathy) A¯^vfvweK gvbwmK Ae¯’v †hgb- wjfv‡ii KvRK‡g© Amyweavi Kvi‡Y Z›`ªv”QbœZv, m‡›`n A_ev †Kvgv| nvBcvi_vBi‡qwWRg (Hyperthyroidism) Ggb GKwU Ae¯’v †hLv‡b _vBi‡qW MÖwš’ AwZwi³ gvÎvq _vBi‡qW ni‡gvb ˆZwi K‡i Ges wbtmiY K‡i| GB Ae¯’vi wKQz jÿY †hgb- wWwjwiqvg, Kuvcywb, D”P i³Pvc Ges ü`wc‡Ði ª`æZ MwZ- A¨vj‡Kvnj †Q‡o †`evi c‡ii jÿ‡Yi mv‡_ wg‡j †h‡Z cv‡i| nvBcvi †fw›U‡jkb (Hyper Ventilation) A¯^vfvweKfv‡e ¯^vm-cÖk¦vm, †hwU nvB‡cvK¨vcwbqvi (i‡³ Kve©b-WvB-A·vB‡Wi AwZwi³ Kg gvÎv) d‡j m„wó nq| GwU wkiwki A_ev AvOz‡j I gy‡Li cv‡k wcb Ges myB †dvUv‡bv, ey‡Ki e¨v_v Ges gv_v †Nviv‡bvi g‡Zv jÿY ˆZwi K‡i| nvB‡cvMøvB‡mwgqv (Hypoglycaemia) i‡³ Møy‡KvR (myMvi) A¯^vfvweK gvÎvq K‡g hvIqv| nvB‡cvb¨vUªvwgqv (Hyponatraemia) i‡³ †mvwWqv‡gi (jeY) A¯^vfvweK iK‡gi Kg NbZ¡| nvB‡cv_vBi‡qwWRg (Hypothyroidism) _vBi‡qW MÖwš’i Kg Kvh©KvwiZv| cÖvßeq¯‹ e¨w³‡`i g‡a¨ wKQz jÿY, †hgb- Aemv`, wbw®ŒqZv, IRb †e‡o hvIqv Ges gb Lvivc _vKv, †h¸‡jv welYœZvi mv‡_ wg‡j †h‡Z cv‡i| hw` Rb¥Kvjxb mg‡q Ges wPwKrmv bv Kiv‡bv Ae¯’vq _v‡K, Zvn‡j GwU eyw× cÖwZewÜZv ˆZwi Ki‡Z cv‡i Ges Zvi weKvk evavcÖvß n‡Z cv‡i| B›Uvicvi‡mvbvj †_ivwc (Inter Personal Therapy) gvbwmK wPwKrmv †hwU welYœZvg~jK jÿY Ges AvšÍtmvgvwRK mgm¨vi we‡klZt ÿwZ, Ø›Ø, GKvKxZ¡ Ges Rxe‡bi D‡jøL‡hvM¨ †Kvb cwieZ©‡bi mv‡_ wgj‡K †Rvi †`q| B›Uªywmf †g‡gvwiR (Intrusive Memories) GKwU gvbwmK AvNv‡Zi d‡j evievi, AcÖZ¨vwkZ, hš¿Yv`vqK ¯§„wZ| Av‡qvwWb †Wwdwm‡qbwm (Iodine Deficiency) GKwU Ae¯’v †hLv‡b _vBi‡qW ni‡gv‡bi ¯^vfvweK Drcv`‡bi Rb¨ kix‡i cÖ‡qvRbxq Av‡qvwW‡bi NvUwZ _v‡K, hv weKvk‡K cÖfvweZ K‡i| LvZ (Khat) K¨v_v GWzwjm bv‡gi GKwU ¸‡j¥i cvZv, †hLv‡b DÏxcK Dcv`vb i‡q‡Q| GwU we‡bv`bg~jK gv`K I gv`‡Ki Dci wbf©ikxjZv ˆZwi K‡i| jM †ivj (Log Roll) ¯úvBbvj K‡W©i ÿwZ Kgv‡bvi Rb¨ GKRb gvbyl‡K Nvo A_ev †Kvgi SuyKv‡bv ev‡` GK cvk †_‡K Ab¨ cv‡k miv‡bv| †gwWK¨vwj AvbG·‡cøBÛ c¨vivjvBwmm (Medically Unexplained Paralysis) †Kvb AM©vwbK KviY QvovB kix‡ii GKwU As‡ki †Rvi AvswkK A_ev cy‡ivcywi K‡g hvIqv| †gwbb‡Rwbqvj Bwi‡Ukb (Meninganial Irritation) mvaviYZ GKwU msµg‡Yi Kvi‡Y gw¯Í®‹ Ges ¯úvBbvj KW©‡K Ave„Z K‡i iv‡L †h AveiY Zvi wUmy¨i Bwi‡Ukb| †gUvewjK A¨vebigvwjwU (Metabolic Abnormality) kix‡ii ni‡gvb, wgbv‡ij, B‡j‡±ªvjvBU A_ev wfUvwg‡bi A¯^vfvweKZv| †gvwb©s (mourning) †Mvcb A_ev mK‡ji m¤§y‡L g„‡Zi cÖwZ GKRb gvby‡li g‡bv‡hvM †`qv, we`vq Rvbv‡bv Ges ¯§„wZ †ivgš’b Kivi cÖwµqv| †kvKZvc Kivi ixwZbxwZi g‡a¨ i‡q‡Q †klK…Z¨ Kiv Ges Kvco cwieZ©b Kiv, N‡i _vKv Ges Dcevm Kivi g‡Zv AvPiY| wbD‡ivBb‡dKkb (Neuroinfection) gw¯Í®‹ Ges/A_ev ¯úvBbvj K‡W©i mv‡_ mswkøó msµgY| wbD‡iv‡jcwUK g¨vwjMb¨v›U wmb‡Wªvg (Neuroleptic Malignant Syndrome) cÖ` vn cÖkgb Kivi Rb¨ e¨eüZ Ily‡ai GKwU MÖæc| G¸‡jv cÖvqB e¨envi Kiv nq e¨_v Kgv‡bvi Rb¨ (†hgb- AvB‡mvcÖæ‡db GKwU GbGmGAvBwW) AwcI‡qU (Opiate) Avwdg cwc †_‡K D™¢yZ GKwU gv`K ª`e¨| AwcI‡qU e¨v_v Kgv‡bvi Rb¨ Lye Kvh©Kix, wKš‘ G¸‡jv †bkv ˆZwi K‡i Ges wbf©ikxjZv ˆZwi Ki‡Z cv‡i| †n‡ivBb GKwU AwcI‡qU| A‡_©v÷¨vwUK nvB‡cv‡Ubkb (Orthostatic hypotension) hLb GKRb Ae¯’vb cwieZ©b K‡ib, ZLb nVvr K‡i i³Pvc K‡g hvIqv| †hgb- †kvqv Ae¯’v †_‡K e‡mb ev `uvovb, †hUv gv_v nvjKv A_ev gv_v †Nvivi Abyf‚wZ ˆZwi K‡i| 71 cwj‡_ivwc (Polytherapy) GKwU Ae¯’vi Rb¨ GKB mg‡q G‡Ki AwaK Ily‡ai cÖ‡qvM| c‡Ubwkqvwj UªgvwUK B‡f›U (Potentially traumatic event) †h †Kvb SzuwKc~Y© A_ev fqsKi NUbv †hgb- kvixwiK A_ev †hŠb wbh©vZb, †Kvb Ab¨vq cÖZ¨¶ Kiv, GKRb gvby‡li Nievwo fvOv, A_ev ¸iæZi `yN©Ubv ev AvNvZ| mswkøó gvbylwUi Av‡eMxq cÖwZwµqvi Ici wbf©i Ki‡e Gme NUbv gvbwmK AvNvZ wn‡m‡e we‡eP¨ n‡e wK-bv| cÖe‡jg-mjwfs KvD‡Ýwjs (Problem-Solving counseling) gvbwmK wPwKrmv, hv‡Z AšÍfy©³ i‡q‡Q GKwU wbw ©`ó msL¨K †mkb a‡i mgm¨v mbv³KiY Ges mgm¨v mgvav‡bi GKwU mymse× †KŠkj| cÖe‡jg-mjwfs †UKwbKm (Problem-solving techniques) GwU GKRb gvby‡li mv‡_ KvR Kivi gva¨‡g mgvavb †ei Kiv Ges mgm¨vi mv‡_ Lvc LvIqv‡bvi †KŠkj| mgm¨vwU mbv³ K‡i, ¸iæZ¡ ey‡S Ges wKfv‡e mgm¨vi mgvavb Kiv hvq Ges Gi †KŠkj¸‡jv wb‡q Av‡jvPbv Kiv hvq| GgGBPM¨v‡c, ÒcÖe‡jg mjwfs KvD‡ÝwjsÓ wn‡m‡e GB †KŠkj¸‡jv GKwU wbw`©ó msL¨K †mkb a‡i mymse×fv‡e e¨envi Kiv nq| wmD‡WvwmRvi (Pseudoseizure) GKwU Ae¯’v hv GKwU Gwc‡jwÞK wmRvi wn‡m‡e cÖZxqgvb n‡Z cv‡i, wKš‘ Avm‡j Zv bq| Ávb nviv‡bv Ges Pjv‡div m¤c‡K© Zviv Gwc‡jcwUK wmRv‡ii g‡Zv n‡Z cv‡i, hw`I wRnŸvq Kvgo †`Iqv, c‡o hvevi `iæY gvivZ¥K Kvjwk‡U `vM Ges cÖmªve a‡i ivL‡Z AcviMZv BZ¨vw` welq¸‡jv LyeB `yj©f| GB ch©vq¸‡jv Gwc‡jcwUK wmRv‡ii B‡jKwUªKvj Gw±wfwU †`Lvq bv| j¶Y¸‡jv †Kvb GKwU wbD‡ivjwRK¨vj Ae¯’vi Kvi‡Y nq bv A_ev GKwU gv`K A_ev Ily‡ai cÖZ¨¶ cÖfv‡ei Kvi‡YI nq bv| AvBwmwW-11 cÖ¯Ív‡e GB ch©vq¸‡jv wW‡mvwm‡qwUf †gvUi wWmAW©v‡i AšÍf©y³| mvB‡KvjwRK¨vj dv÷©-GBW (wcGdG) [Psychological first aid (PFA)] wec‡` hviv i‡q‡Qb,Ges hviv m¤cÖwZ GKwU msK‡Ui gy‡LvgywL n‡q‡Qb Zuv‡`i Rb¨ mnvqK †mevcÖ`vb| GB †mevi g‡a¨ i‡q‡Q Zvr¶wYK Pvwn`v Ges cÖ‡qvR‡bi g~j¨vqb; cÖv_wgK Pvwn`v¸‡jv `ªæZ wbwðZ Kiv, mvgvwRK mnvqZv Zivwš^Z Kiv; Ges cybivq ¶wZ †_‡K myi¶v †`Iqv| wi‡MÖwmf we‡nwfqvi (Regressive behavior) GKwU ev”Pvi mwZ¨Kvi weKv‡ki mv‡_ mvgÄm¨c~Y© bq, eis AviI Kg eq‡mi Kv‡iv mv‡_ mvgÄm¨c~Y© AvPiY| mPivPi D`vniY¸‡jv njt weQvbvq g~ÎZ¨vM Kiv Ges ev”Pv‡`i mv‡_ Lye †ewk †gjv‡gkv Kiv| †imwc‡iUwi wW‡cÖkb (Respiratory depression) A¯^vfvweK Kg gvÎvq k¦vm-cÖk¦vm, hvi djkÖæwZ‡Z Aw·‡Rb mieivn K‡g hvq| mPivPi KviY¸‡jv nj gw¯Í‡®‹i AvNvZ Ges †bkv (†hgb- †eb‡RvWvqv‡Rwcb)| wmRvi (Seizure) A¯^vfvweK B‡jw±ªK¨vj wbtmi‡Yi Kvi‡Y gw¯Í‡®‹i Kv‡R e¨vNvZ| †mjd-nvg© (Self-harm) wb‡Ri cÖwZ AvNvZ A_ev wb‡R wb‡RB welwµqv, hvi D‡Ïk¨ A_ev djvd‡j ¸iæZi n‡Z cv‡i ev bvI n‡Z cv‡i| †mjd-‡gwW‡KwUs (Self-medicating( ¯^v¯’¨ †ckvRxexi mv‡_ Av‡jvPbv QvovB kvixwiK A_ev gvbwmK mgm¨v Kgv‡bvi Rb¨ wb‡R wb‡RB A¨vj‡Kvnj A_ev gv`K †bIqv| †mcwmm (Sepsis) gvivZ¥K msµg‡Yi Kvi‡Y RxebNvZx GKwU Ae¯’v, R¡i, msenbZ‡š¿i fvimvg¨ bó Ges A‡½i Kg©nxbZv hvi jÿY| kK (Shock) GKwU Ae¯’v †hLv‡b msµgY A_ev welwµqvi Kvi‡Y i³Pvc Ggb ch©v‡q †b‡g hvq, hv GKRb gvby‡li †eu‡P _vKvi Rb¨ Dchy³ bq| j¶‡Yi g‡a¨ i‡q‡Q Kg A_ev kbv³ Kiv hvq bv Ggb i³ Pvc, VvÐv Z¡K, GKwU y`e©j A_ev Abycw¯’Z cvjm, k¦vm wb‡Z Kó nIqv Ges m‡PZbZv n«vm cvIqv| GmGmAviAvB (SSRI) wm‡jKwUf †m‡ivUwbb wiAvc‡UK BbwnweUit A¨vw›UwW‡cÖm¨v›U Ily‡ai GKwU †kªYx| hv wba©vwiZfv‡e †m‡ivUwb‡bi wiAvc‡UK eÜ K‡i †`q| †m‡ivUwbbnj gw¯Í‡®‹i ivmvqwbK evZ©vevnK (wbD‡iv UªvÝwgUvi) hv gvby‡li †gRv‡Ri Ici cÖfve iv‡L| d¬yI·wUb GKwU GmGmAviAvB| †÷i‡qWm (Steroids) ni‡gv‡bi Ggb GKwU MÖæc hv Ilya wn‡m‡e cvIqv hvq, msµgY, Uw·b Ges Ab¨vb¨ †ivM cÖwZ‡iva m¤cwK©Z †iv‡Mi cÖwµqv eÜ Kivi gZ ¸iæZ¡c~Y© KvR K‡i| †÷i‡qW Ily‡ai g‡a¨ i‡q‡Q Møy‡KvKwUK‡qWm (†hgb- †cÖWwb‡mv‡jvb) Ges ni‡gvbvj K›Uªv‡mcwUfm| w÷‡fbm-Rbmbwmb‡Wªvg (Stevens-Johnson syndrome) e¨_vmn Pvgov IVv, Avjmvi, †dv¯‹v Ges gyL, †VuvU, Mjv, wRnŸv, †PvL I †hŠbv‡½ wgD‡KvwKD‡Ubvm wUmy¨i KwVb AveiY, gv‡S gv‡S R¡i BZ¨vw` j¶‡Yi gva¨‡g cÖKvwkZ Rxe‡bi Rb¨ ûgwK ¯^iƒc GKwU Ae¯’v| GwU †ewki fvM †¶‡Î Ily‡ai cÖwZwµqv we‡klZ A¨vw›UGwc‡jwÞK Ily‡ai Kvi‡Y n‡q _v‡K| myBmvBW (Suicide) wb‡Ri g„Z y¨i Rb¨ B”QvK…Zfv‡e †Póv Kiv| wUwmG (TCA) UªvBmvBwK¬K A¨vw›UwW‡cÖm¨v›Ut GK †kÖYxi A¨vw›UwW‡cÖm¨v›U hv G‡Wªbvwjb I †m‡ivUwbb wbD‡iv UªvÝwgUv‡ii wiAvc‡UK eÜ K‡i †`q| D`vni‡Yi g‡a¨ i‡q‡Q A¨vgvBwUªÞvBwjb Ges †K¬vwgcÖvwgb| Ujv‡iÝ (Tolerance) GKB †WvR e¨envi Kiv GKwU gv`‡Ki cÖfve K‡g hvIqv| evievi †me‡bi d‡j kix‡ii Af¨vm n‡q hvevi Kvi‡Y N‡U _v‡K| ZLb GKB cÖfve ˆZwii Rb¨ D”P gvÎvi †WvR cÖ‡qvRb nq| Uw·K GwcWvg©vj b¨v‡µvjvBwmm (Toxic epidermal necrolysis) mvaviYZ GKwU Ilya A_ev msµg‡Yi cÖwZwµqvi d‡j m„ó Pvgov D‡V hvIqvi gZ RxebNvZx Ae¯’v| GwU w÷‡fbm- Rbmb wmb‡Wªv‡gi gZB wKš‘ Av‡iv †ewk Zxeª| UªvgvWj (Tramadol) e¨_v ~`i Kivi/Kgv‡bvi Rb¨ wba©vwiZ Avwdg| GwU gv‡S gv‡S Ace¨envi Kiv nq KviY GwU BD‡dvwiqvi (AwZ Av‡eM A_ev Lywk _vKvi Abyf‚wZ) Abyf~wZ ˆZwi K‡i| †Uªgi (Tremor) Kw¤cZ A_ev SvuKzwbg~jK bovPov, we‡kl K‡i AvOz‡ji| BD‡iv‡mcwmm (Urosepsis) g~Îbvjxi msµg‡Yi Kvi‡Y †mcwmm| Annex 3: Symptom Index (jÿY m~wP) D‡ØM Anxiety Zxeª gvbwmK Pvc Acute Stress( ACU) gvSvwi-¸iæZi welYœZv †ivM Moderate Severe Depressive Disorder (DEP) †cv÷-UªgvwUK †÷ªm wWRAW©vi Post-traumatic Stress Disorder (PTSD) mvB‡Kvwmm Psychosis (PSY) A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Harmful Use of Alcohol and Drugs (SUB) AiæwP Appetite problem Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK (GRI) gvSvwi-¸iæZi welYœZv †ivM Moderate-severe Depressive Disorder (DEP) Ny‡gi g‡a¨ cÖ¯ ªve Bedwetting Zxeª gvbwmK Pvc Acute Stress (ACU) eyw× cÖwZeÜx Intellectual Disability (ID) weåvwšÍ/wØav Confusion mvB‡Kvwmm Psychosis (PSY) g„Mx/wLuPzbx Epilepsy/Seizures (EPI) A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Harmful Use of Alcohol and Drugs(SUB) wWwjDkb Delusions mvB‡Kvwmm Psychosis (PSY) ¯^vfvweK Kvh©µg Pvwj‡q †h‡Z Amyweav Difficulty carrying out usual activities Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv †ivM Moderate-severe Depressive Disorder (DEP) †cv÷-UªgvwUK †÷ªm wWRAW©vi Post-traumatic Stress Disorder (PTSD) mvB‡Kvwmm Psychosis (PSY) eyw× cÖwZeÜx Intellectual Disability (ID) A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Harmful Use of Alcohol and Drugs (SUB) d¬¨vke¨vK Flashbacks Zxeª gvbwmK Pvc Acute Stress (ACU) †cv÷-UªgvwUK †÷ªm wWRAW©vi Post-traumatic Stress Disorder (PTSD) n¨vjywm‡bkb Hallucinations mvB‡Kvwmm Psychosis (PSY) A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Harmful Use of Alcohol and Drugs (SUB) wbivkv Hopelessness Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv †ivM Moderate-severe Depressive Disorder (DEP) Avত্মহZ¨v Suicide (SUI) nvBcvi‡fw›U‡jkb Hyperventilation Zxeª gvbwmK Pvc Acute Stress (ACU) Amshg Incontinence g„Mx‡ivM/wLuPzbxm Epilepsy/Seizures (EPI) eyw× cÖwZeÜx Intellectual Disability (ID) wb`ªvnxbZv Insomnia Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv †ivM Moderate-severe Depressive Disorder (DEP) †cv÷-UªgvwUK †÷ªm wWRAW©vi Post-traumatic Stress Disorder (PTSD) A¨vj‡Kvnj I gv`‡Ki ¶wZKviK e¨envi Harmful Use of Alcohol and Drugs (SUB) Abvn~Z ¯§„wZ Intrusive memories Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK Grief (GRI) †cv÷-UªgvwUK †÷ªm wWRAW©vi Post-traumatic Stress Disorder (PTSD) weiw³ fve Irritability Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv †ivM Moderate-severe DepressiveDisorder (DEP) †cv÷-UªgvwUK †÷ªm wWRAW©vi Post-traumatic Stress Disorder (PTSD) A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Harmful Use of Alcohol and Drugs (SUB) wk¶‡Yi mgm¨v Learning problem eyw× cÖwZeÜx Intellectual Disability (ID) kw³ nªvm Loss of energy Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv †ivM Moderate Severe Depressive Disorder (SDP) 73 Kg AvMÖn, Avb›` Low interest, pleasure Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv Moderate-severe Depressive Disorder (DEP) Lvivc ¯^v¯’¨wewa Poor hygiene mvB‡Kvwmm Psychosis (PSY) eyw× cÖwZeÜx Intellectual Disability (ID) A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Harmful Use of Alcohol and Drugs (SUB) g‡bv‡hvM K‡g hvIqv Reduced concentration Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv Moderate-severe Depressive Disorder (DEP) †cv÷-UªgvwUK †÷ªm wWRAW©vi Post-traumatic Stress Disorder (PTSD) A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Harmful Use of Alcohol and Drugs (SUB) gb Lvivc Sad mood Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv Moderate-severe Depressive Disorder (DEP) wLuPzbx, Kbfvjkb Seizures, convulsions g„Mx/wLuPzbx Epilepsy/Seizures (EPI) A¨vj‡Kvnj I gv`‡Ki ¶wZKi e¨envi Harmful Use of Alcohol and Drugs (SUB) wb‡Ri ÿwZ Kiv/wb‡R‡K AvNvZ Kiv Self-harm AvZ¥nZ¨v Suicide (SUI) mvgvwRK cÖZ¨vnvi Social withdrawal Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv Moderate-severe Depressive Disorder (DEP) mvB‡Kvwmm Psychosis (PSY) e¨vL¨vnxb kvixwiK jÿY Unexplainable physical symptoms Zxeª gvbwmK Pvc Acute Stress (ACU) Zxeª †kvK Grief (GRI) gvSvwi-¸iæZi welYœZv Moderate-severe Depressive Disorder (DEP) †cv÷-UªgvwUK †÷ªm wWRAW©vi Post-traumatic Stress Disorder (PTSD) Avw_©K mn‡hvwMZvq: প্রকাশনা সংক্রান্ত য াগ্াভ াগ্ ঠিকানা mhcphod@bd-actionagainsthunger.org

Ubuvuzi bw’indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe mu bihe vy’ubutabazi Igitabu c’ubutabazi bw’abantu mhGAP (GIH-mhGAP) Indinganizo y’igikorwa co gukuraho agahaze ku magara yo mu mutwe (mhGAP) Cashizwe ahabona n’ishirahamwe mpuzamakungu ry’amagara y’abantu(OMS) mu 2015 hamwe n’ishirahamwe mpuzamakungu ryitaho impunzi(UNHCR) gifise umutwe w’amajambo : mhGAP Humanitarian Intervention Guide (mhGAP-HIG) : clinical management of mental, neurological and substance use conditions in humanitarian emergencies © World Health Organization 2015 Ishirahamwe mpuzamakungu ry’amagara y’abantu (OMS) ryarahaye uburenganzira bwo gusobanura no gushira ahabona igitabu c’ikirundi ibisabwe na Stichting Kennis zonder Grenzen (KzG), ikaba ariyo yonyene ijejwe ubwiza n’ubwizigirwa bw’ico gitabu gisobanuwe mu kirundi. Igihe hoba ukudatahurika neza hagati y’igitabu c’icongereza nic’ikirundi, igitabu c’icongereza nico nyaco kandi kizokwisungwa. Igitabu c’ubutabazi bw’abantu mhGAP (GIH-mhGAP) : Ubuvuzi bw’indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe mu bihe vy’ubutabazi. 1. Indwara zo mu mutwe. 2. Indwara zifatiye ku gufata ibiyayuramutwe. 3. Indwara z’ubwonko n’udutsi nsozabwenge. 4. Gushiranako. 5. Ivyihutirwa. © Stichting Kennis zonder Grenzen 2022 www.kenniszondergrenzen.nl www.samandari.org Gusaba uburenganzira bwo gukoresha kino gitabu. Iki gitabu c’ikirundi kirashobora gusomwa ku mbuga nkurukanabumenyi za Stichting Kennis zonder Grenzen (www.kenniszondergrenzen. nl; www.samandari.org), z’ikigo citaho indwara zo mu mutwe n’izimisi nsozabwenge co mu Kamenge « Centre Neuro-Psychiatrique de Kamenge » (CNPK) n’iza OMS (www.who.int) canke kikagurwa muri CNPK, ibarabara Bwakiro nimero 19, Muyaga, Gihosha, Ntahangwa, Bujumbura, Burundi. Ibijanye no gusobanura no gukoresha kino gitabu bibazwa uwugisomye. Nta na rimwe Stichting Kennis zonder Grenzen izokwigera ibazwa canke ihanirwa ikoreshwa ritabereye rya kino gitabu. Uko uwugikoresheje yocandika: Stichting Kennis zonder Grenzen, Pays-Bas. Guide d’intervention humanitaire mhGAP (GIH-mhGAP) : Prise en charge clinique des troubles mentaux, neurologiques et liés à l’utilisation de substances psychoactives dans les situations d’urgence humanitaire. Bujumbura : KzG, 2022. iMu gihe ca none, isi itegerezwa guhagurukira igitigiri kitagira uko kingana c’abantu bakeneye ubufasha bwihuta bitewe n’intambara hamwe n’ibiza. Igitigiri c’impunzi n’abantu bakuwe muzabo mu bihugu vyabo, nticari carigeze kuba kinini nk’ubu kuva intambara ya kabiri y’isi yose irangiye. Igitigiri cababa imiriyoni cumi z’abantu cane cane mu karere k’ibihugu vy’Abarabu, muri Afurika na Aziya bakeneye kwitabwaho vyihuta, cane cane mu kuronswa ubufasha mu vya nkenerwa bikomeye vy’abantu vyerekeye amagara yo mu mutwe. Abakuze n’abana bari mu bihe bikeneye ubufasaha bwihuta barafatwa n’indwara zo mu mutwe, z’imitsi nsozabwenge hamwe n’iziterwa no gufata ibiyayuramutwe. Abenshi muri bo baba bari mu gihe c’ikigandaro n’ihungabana ry’umushuhira, bifatwa nk’inyifato isanzwe yo mu vyiyumviro kandi imara akanya gato, mu gihe gikomeye c’ivyago. Yamara, ku bantu b’inkehwa, ico gihe kiratuma bagira ingorane ku magara yo mu mutwe zikabatera n’indwara z’ukuyinga, uguhahamuka canke ikigandaro kidasanzwe, bishobora gutuma ibikorwa vyo mu buzima bwa minsi yose bihungabana. Kukaba nkako, abantu bari basanzwe bafise indwara zikomeye nk’ibisazi, ubukehabwenge canke intandara bacika cane abanyantegenke kubwo kwiyunguruza, uguhebwa canke kubura ubufasha mu vy’amagara. Mu kurangiza, ukunywa inzoga canke ugufata ibiyayuramutwe biratera ingorane zikomeye mu bijanye n’amagara y’abantu n’amabi afatiye ku gitsina. Ni mu gihe ivya nkenerwa ku magara yo mu mutwe y’abantu bibaye vyinshi, ubushobozi buhasanzwe buca buba buke. Mu gihe nk’ico, ibikoresho bibangutse kandi vyoroshe gukoresha birakenewe cane. Iki gitabu cakozwe hagumijwe ku muzirikanyi izo ngorane nyezina. Igitabu c’ubutabazi bw’abantu mhGAP ni igikoresho kibangutse kandi coroshe gukoresha, gifise intumbero yo gufasha ibigo vyitaho amagara y’abantu muri rusangi mu gihe c’ubutabazi, mu gusuzuma no kuvura indwara zo mu mutwe, iz’imitsi nsozabwenge n’iziterwa no gufata ibiyayuramutwe. Ni ihinyanyurwa ry’igitabu mhGAP (2010) c’ishirahamwe mpuzamakungu ryitaho amagara y’abantu (OMS) kugira gikoreshwe mu bihe vy’ubutabazi bw’abantu. Ni igitabu cakozwe hisunzwe ibikunze kwibonekeza mu kuvura ben’izo ndwara, mu bigo vyitaho amagara y’abantu bidasanzwe bivura izo ndwara. Iki gitabu kirajanye neza n’intumbero z’umurwi wamaho mpuzamashirahamwe (CPI) mu bijanye n’amagara yo mu mutwe n’ubufasha mu mibano n’inyifato mu gihe c’ubutabazi Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support and Settings hamwe n’intumbero ngenderwako z’ishirahamwe mpuzamakungu ryitaho impunzi (UNHCR) mu gutunganya ibikorwa ku mpunzi - Amagara yo mu mutwe n’ubufasha mu mibano n’inyifato UNHCR Operational Guidance for Mental Health and Psychosocial Support in Refugee Operations ziharanira ubufasha bwo ku mpande nyinshi mu kurwanya ingaruka mbi mu migenderanire n’amagara yo mu mutwe mu bihe vy’ubutabazi no kwimurwa. Iryo shirahamwe riranaterera kandi mw’ishirwa mu ngiro ry’ihangiro nyamukuru ry’integuro rusangi y’ibikorwa vy’Ishirahamwe mpuzamakungu ryitaho amagara y’abantu (OMS) mu gisata c’amagara yo mu mutwe 2013- 2020, na cane cane ubufasha bwo gukingira ikibano n’amagara meza yo mu mutwe. Turasaba abegwa n’ivy’ubufasha mu gisata c’amagara y’abantu ko bokwakira bakongera bagakwiragiza ako gatabu nkenerwa, mu ntumbero y’ukugabanya ububabare no gufasha abakuze n’abana barwaye indwara zo mu mutwe mu bihe vy’ubutabazi mu kurengera ibihe bidasanzwe. Gushikiriza Margaret Chan Umuyobozi mukuru Ishirahamwe mpuzamakungu ryitaho amagara António Guterres Ishirahamwe mpuzamakungu ryitaho impuzi (UNHCR)

iii Remerciements de l’original . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Remerciements de l’édition en kirundi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Intangamarara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Impanuro ku baserukira ubuvuzi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Ingingo ngenderwako z’ubuvuzi bw’abagendana indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe mu bihe vy’ubutabazi . . . . . . . . . . . 5 1. Ingingo zo kuganira . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Ingingo zo gusuzuma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 3. Ingingo zo gutanga ubufasha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 4. Ingingo zo kugabanya uruhagara no gukomeza gushigikirana mu kibano . . . . . . . . 9 5. Ingingo zo gukingira agateka ka zina muntu. . . . . . . . . . . . . . . . . . . . . . . . . 11 6. Ingingo zo kwitwararika gufatiye ku mibereho myiza . . . . . . . . . . . . . . . . . . . 12 Module 1. Uruhagarara rw’umushuhira rwo mu mutima (STR) . . . . . . . . . . . . . . . . . . . . . 13 2. Ikigandaro (DEU) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3. Ukuyinga n’akabonge (DEP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 4. Ihahamuka (ESPT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 5. Indwara yo mu mutwe yeruye (PSY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 6. Intandara/Ibisahuzi (EPI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 7. Ubukehabwenge (DI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 8. Gufata inzoga n’ibiyayuramutwe bifise ingaruka mbi (SUB). . . . . . . . . . . . . . . . . 45 9. Ukwiyahura (SUI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 10. Izindi ndwara zihambaye z’amagara yo mu mutwe (AUT). . . . . . . . . . . . . . . . . . 55 Ivyongeweko Ivyongeweko 1: Uburyo bwo gutanga amakuru y’ubuvuzi (SIS) – Insiguro y’indwara – UNHCR (2014) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Ivyongeweko 2 : Insiguro y’amajambo agoye . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Ivyongeweko 3. Urutonde rw’ibimenyetso vy’indwara. . . . . . . . . . . . . . . . . . . . . 62 Ibirimwo iv Remerciements de l’original Conceptualisation Mark van Ommeren (OMS), Yutaro Setoya (OMS), Peter Ventevogel (UNHCR) et Khalid Saeed (OMS), sous la direction de Shekhar Saxena (OMS) et Marian Schilperoord (UNHCR) Rédaction et édition Peter Ventevogel (UNHCR), Ka Young Park (Harvard Kennedy School) et Mark van Ommeren (OMS) Équipe de révision mhGAP de l’OMS Nicolas Clark, Natalie Drew, Tarun Dua, Alexandra Fleischmann, Shekhar Saxena, Chiara Servili, Yutaro Setoya, Mark van Ommeren, Alexandra Wright et M. Taghi Yasamy Autres contributeurs/réviseurs Helal Uddin Ahmed (National Institute of Mental Health, Bangladesh), Corrado Barbui (Centre collaborateur de l’OMS pour la recherche et la formation en santé mentale, Université de Vérone), Thomas Barrett (University of Denver), Pierre Bastin (Comité international de la Croix-Rouge), Myron Belfer (Harvard Medical School), Margriet Blaauw (Groupe de référence du Comité permanent interorganisations (CPI) pour la santé mentale et le soutien psychosocial dans les situations d’urgence), Boris Budosan (Malteser International), Kenneth Carswell (OMS), Jorge Castilla (ECHO- Commission européenne), Vanessa Cavallera (OMS), Elizabeth Centeno-Tablante (OMS), Lukas Cheney (University of Melbourne), Rachel Cohen (Common Threads), Ana Cuadra (Médecins du Monde, MdM), Katie Dawson (University of New South Wales), Joop de Jong (Université d’Amsterdam), Pamela Dix (Disaster Action), Frederique Drogoul (Médecins Sans Frontières, MSF), Carolina Echeverri (UNHCR), Rabih El Chammay (ministère de la Santé publique du Liban), Mohamed Elshazly (International Medical Corps, IMC), Michael First (Colombia University), Richard Garfield (Centers for Disease Control and Prevention, CDC), Anne Golaz (Université de Genève), David Goldberg (King’s College London), Marlene Goodfriend (MSF), Margaret Grigg (MIND Australie), Norman Gustavson (PARSA Afghanistan), Fahmy Hanna (OMS), Mathijs Hoogstad (indépendant, Pays-Bas), Peter Hughes (Royal College of Psychiatrists, Royaume-Uni), Takashi Izutsu (Banque mondiale), Lynne Jones (Harvard School of Public Health), Devora Kestel (Organisation panaméricaine de la santé/OMS), Louiza Khourta (UNHCR), Cary Kogan (University of Ottawa), Roos Korste (in2mentalhealth, Pays-Bas), Marc Laporta (McGill University), Jaak Le Roy (indépendant, Belgique), Barbara Lopes-Cardozo (CDC), Ido Lurie (Physicians for Human Rights-Israël), Andreas Maercker (Université de Zürich), Heini Mäkilä (International Assistance Mission, Afghanistan), Adelheid Marschang (OMS), Carmen Martínez-Viciana (MSF), Jessie Mbwambo (Muhimbili University of Health and Allied Sciences, Tanzanie), Fernanda Menna Barreto Krum (MdM), Andrew Mohanraj (CBM, Malaisie), Emilio Ovuga (Gulu University, Ouganda), Sarah Pais (OMS), Heather Papowitz (UNICEF), Xavier Pereira (Taylor’s University School of Medicine and Health Equity Initiatives, Malaisie), Pau Perez-Sales (Hospital La Paz, Espagne), Giovanni Pintaldi (MSF), Bhava Poudyal (indépendant, Azerbaijan), Rasha Rahman (OMS), Ando Raobelison (World Vision International), Nick Rose (Oxford University), Cecile Rousseau (McGill University), Khalid Saeed (OMS), Benedetto Saraceno (Universidade Nova de Lisboa, Portugal), Alison Schafer (World Vision International), Nathalie Severy (MSF), Pramod Mohan Shyangwa (IOM), Yasuko Shinozaki (MdM), Derrick Silove (University of New South Wales), Stephanie Smith (Partners in Health), Leslie Snider (War Trauma Foundation), Yuriko Suzuki (National Institute of Mental Health, Japon), Saji Thomas (UNICEF), Ana María Tijerino (MSF), Wietse Tol (Johns Hopkins University et Peter C Alderman Foundation), Senop Tschakarjan (MdM), Bharat Visa (OMS), Inka Weissbecker (IMC), Nana Wiedemann (Fédération internationale des Sociétés de la Croix-Rouge et du Croissant-Rouge) et William Yule (King’s College London). Financement Haut-Commissariat des Nations Unies pour les réfugiés (UNHCR) vTitre de l’édition en français originale de l’OMS Guide d’intervention humanitaire mhGAP (GIH-mhGAP) : prise en charge clinique des troubles mentaux, neurologiques et liés à l’utilisation de substances psychoactives dans les situations d’urgence humanitaire Cadre de la traduction Centre Neuro-Psychiatrique de Kamenge (CNPK, Burundi) Organisation Amy BESAMUSCA-EKELSCHOT (Stichting Kennis zonder Grenzen, KzG), Gladys DUSHIME (CNPK) Rédaction et édition Michel NDIKUMANA (CNP Ngozi), Amy BESAMUSCA-EKELSCHOT (Stichting Kennis zonder Grenzen, KzG) Équipe de traduction GIH-mhGAP en kirundi Michel NDIKUMANA (CNP Ngozi), Gladys DUSHIME (CNPK), Godelive NIMUBONA (CNPK), Pierre NDAYISHIMIYE (CNPK), Paula UWIMANA (CNPK) Financement Traduction : Stichting Kennis zonder Grenzen (KzG, La fondation ubumenyi butagira imbibe, Pays-Bas) Mise en page : UNHCR Dessin couvre Lisa Malou SMITS, Jannick BESAMUSCA Remerciements de l’édition en kirundi vi 1Intangamarara Iki gitabu ni ihinyanyurwa ry’ igitabu « mhGAP (GI-mhGAP) » c’ishirahamwe mpuzamakungu ryitaho amagara (OMS) mu kurwanya indwara zo mu mutwe, indwara z’imitsi nsozabwenge hamwe n’iziva k’ugufata ibiyayuramutwe mu bigo vyitaho amagara y’abantu bitabifitiye ubuhinga kugira zigikoreshe mu bihe vy’ubutabazi. Ijambo ry’umutwe ry’ico gitabu ni « Igitabo c’ubutabazi bw’abantu mhGAP (GIH-mhGAP) ». ndwara na cane cane mu bihugu bikenye n’ibiri mu nzira y’amajambere. Birashobora kwega abaganga basanzwe canke abavuzi hamwe n’abakirizi n’abandi baganga harimwo n’abahinga babinonosoye mu bindi bisata bitajanye n’ubuvuzi bw’indwara zo mu mutwe niz’indwara z’imitsi nsozabwenge. Hejuru y’ico gitabu, indinganizo mhGAP iratanga ibikenewe vyinshi vyokoreshwa mw’ishirwa mu ngiro ry’indinganizo mu kwihweza no mu guhinyanyura indinganizo, inyigisho, ubugenduzi n’ikurikirana1. mhGAP ni iki ? Kuki ukwisunga igihe c’ubutabazi ari nkenerwa ? Ibihe vy’ubutabazi birafise izindi ndwara zishika bukwinabukwi n’izindi ngendanwa zimara umwanya munini zatewe n’intambara y’abantu bitwaje ibirwanisho, ibiza bisanzwe n’ibivuye mu mahinguriro. Ibihe bigoye hakenewe ubutabazi bwihuta abantu benshi barahunga. Ivya nkenerwa vy’ibanze vy’abanyagihugu birarengeye ubushobozi bwaho hantu mu gihe ibijanye n’intwaro yo mukarere vyononekaye bitewe n’ikiza. Uburyo burahinduka bivanye n’uko bubashikira kandi n’ukuboneka kw’ubufasha bwo mu karere, mu gihugu no kw’isi yose. Iyo amagume ateye ibibazo vyinshi, aratanga kandi amahirwe menshi ku bavuzi bo mu bisata vy’amagara nk’ugushaka kw’intwaro n’uburyo bwinshi mu gushiraho no mu kwongereza ibisata vy’amagara yo mu mutwe2. Ingorane nyamukuru n’izi zikurikira : » Icihuta gikomeye n’ukuraba ibikenewe biza imbere y’ibindi hamwe no gukwiragiza ivya nkenerwaa bike bisanzwe bihari  » Umwanya udakwiye wo kwigisha abavuzi  » Ubukene bw’abahinga (mu bijanye n’ukwigisha, ukugendura, ugushigikira no gutanga intumbero mu gusuzuma umurwayi)  » Ubukene bw’imiti buvuye kw’ihungabana ry’urukurikirane rwo kuyirondera. Igitabu c’ubutabazi mhGAP cakozwe kugira gifashe mu gutorera inyishu izo ngorane nyezina mu bihe vy’ubutabazi. 1 Saba ivyo bikoresho kuri mhgap-info@who.int. 2 Isunge ishirahamwe mpuzamakungu ry’amagara (OMS). Reconstruire en mieux – Pour des soins de santé mentale durables après une situation d’urgence. OMS : Genève, 2013. Ugusubira kwubaka bishimishije –kugira haboneke ubuvuzi buramba bw’amagara yo mu mutwe inyuma y’ibihe vy’ubutabazi. OMS : Génève, 2013 Indinganizo y’ibikorwa yo gukuraho agahaze mu magara yo mu mutwe canke mhGAP (mu congereza « mental health Gap Action Programme »), ni indinganizo y’ishirahamwe mpuzamakungu ryitaho amagara y’abantu (OMS) iharanira gutora inyishu y’ubukene bw’ubuvuzi bw’abantu bafise indwara zo mu mutwe, z’imitsi nsozabwenge n’iziva kugufata ibiyayuramutwe (MNS) bakeneye. Mw’iyo ndinganizo, igitabu c’ubutabazi mhGAP (GI-mhGAP) cashizwe ku mu garagaro mu mwaka 2010. Igitabu GI-mhGAP ni igitabu gifasha kumenya ibimenyetso vy’indwara zo mu mutwe, z’imitsi nsozabwenge hamwe n’iziva ku gufata ibiyayuramutwe, cagenewe abavuzi b’indwara zisanzwe bakora mu bigo bidasanzwe bifise ubuhinga mukuvura ben’izo Ibiri mu gitabu » Ibigabane bigufi mu gusuzuma no mu kuvura indwara zikurikira: ◆ Uruhagarara rw’umushuhira rwo mu mutima (STR) ◆ Ikigandaro (DEU) ◆ Ukuyinga (DEP) ◆ Ihahamuka (ESPT) ◆ Indwara zo mumutwe zeruye (PSY) ◆ Intandara (EPI) ◆ Ubukehabwenge (DI) ◆ Ukwizizirwa n’ibiyayuramutwe (SUB) ◆ Ukwiyahura (SUI) ◆ Izindi ndwara zihambaye zo mu mutwe (AUT) Ibindi vyahindutse ni ibi bikurikira : » Impanuro kw’ihungabana ry’inyifato zarasubiriye kwandikwa mu buryo bw’impanuro kubijanye n’ingorane z’inyifato ku miyabaga, dusanga mu kigabane kiraba izindi ndwara zihambaye zerekeye amagara yo mutwe (AUT). » Ikigabane c’ugusuzuma n’ukuvura indwara zijanye n’uruhagarara (mhGAP : OMS 2013) cagabuwe mu mice itatu : Uruhagarara rw’umushuhira rwo mu mutima (STR), ikigandaro (DEU), n’ihahamuka (ESPT). Igitabu c’ubutabazi mhGAP kirimwo amabwirizwa y’ubufasha bw’ibanze bw’indwara zo mu mutwe z’imitsi nsozabwenge n’izifatiye kugufata ibiyayuramutwe ku bavuzi batanonosoye ben’izo ndwara mu gihe c’ubutabazi aho abahinga babinonosoye hamwe n’ubuvuzi bikenye. Iki gitabu gisubiramwo ibimenyeshejwe vya nkenerwa vy’igitabo GI-mhGAP kandi congeramwo ibindi nyezina bijanye n’ibihe bidasanzwe vy’ubutabazi. Iki gitabu kirimwo ibintu bikurikira : » Impanuro ku baserukira ubuvuzi ; » Ingingo ngenderwako zikoreshwa mu bihe vy’ubutabazi harimwo : ◆ Ugutanga ubufasha mu bisata vyinshi bijanye n’intumbero y’umurwi wamaho mpuzamashirahamwe (CPI) yerekeye amagara yo mu mutwe n’ubufasha mu nyifato n’imibano mu bihe vy’ubutabazi (CPI/IASC, 2007), hamwe n’iy’ishirahamwe mpuzamakungu ryitaho impunzi (UNHCR), munteguro y’ibikorwa bizerekeye – amagara yo mu mutwe, ubufahsa mu nyifato n’imibano (UNHCR, 2013) hamwe n’ibindi bikoresho bikenewe vyerekeye ubutabazi bw’abantu ; ◆ Inyigisho zijanye no kugabanya uruhagarara. 2 » Insiguro y’amajambo agoye yarongewemwo. Amajambo yashizweko akanyenyeri * yarasiguwe mu gace ka kabiri k’ivyongeweko. Iki gitabu ni gito cane ugereranije n’igitabu GI-mhGAP. Nta mpanuro gifise ku vyerekeye : » Ukwizizirwa* n’ukumererwa nabi bivuye ku nzoga n’ibiyayuramutwe (naho biruko ingaruka mbi zijanye n’uguhagarika inzoga hamwe no gufata ibiyayuramutwe ziravugwa muri iki gitabu) ; » Indwara y’igabanuka ry’ukugaba no kutaguma hamwe (naho ingorane z’inyifato ku miyabaga zavuzwe muri iki gitabu mu kigabane c’izindi ndwara zihambaye z’amagara yo mu mutwe) ; » Indwara zifata abana zitera ihungabana mw’ikora ry’ubwonko; umwana ntagire imigenderanire n’abandi, agira inyifato ziguma zigaruka n’ingorane z’ukuvuga ; » Indwara y’igabanuka ry’ubushobozi bwo kwibuka (naho ubufasha buhabwa abitaho abantu barwaye indwara zo mumutwe, iz’imitsi nsozabwenga, n’iziva kugufata ibiyayuramutwe bwavuzwe mu ingingo ngenderwako z’ubuvuzi buri mw’ico gitabu) ; » Ikintu kitaza bukwi na bukwi gishobora gutuma umuntu yigirira nabi » Ubuvuzi ku rugezo rwa kabiri ku ndwara nyinshi zo mumutwe, iz’imitsi nsozabwenge n’iziva ku gufata ibiyayuramutwe. Impanuro kw’izo ndwara ziraboneka mu gitabu gikwiye ca GI-mhGAP. 3Ugushira indwara zo mu mutwe, indwara z’imitsi nsoza bwenge, n’iziterwa no kunywa inzoga hamwe no gufata ibiyayuramutwe (MNS) mu buvuzi busanzwe gutegerezwa gusuzumwa n’umuyobozi (uwuserukira amagara y’abantu mu karere, umuyobozi mukuru w’ubuvuzi mw’ishirahamwe n’abandi) ajejwe gutegura hamwe no gukurikirana ubuvuzi mu bigo vyinshi vy’ubuvuzi inyuma yo kwihweza uko bimeze (raba le vade-mecum mu bihe vy’ubutabazi bw ‘abantu bw’amashirahamwe OMS na UNHCR [2012]). Buri kigo cose gifise umuyobozi w’ubuvuzi (umuyobozi mukuru w’ikigo c’ubuvuzi) afise ibikorwa ashinzwe. Abaserukira ubuvuzi bategerezwa kwitaho ibintu bikurikira. Ibidukikije » Hasabwa ko ata kimenyetso na kimwe coshirwa aho hantu kugira barinde ko ubufasha bw’izo ndwara bwokwankwa mu gutinya gutumwa agatoke mu kibano. » Gutegura ikibanza ciherereye, vyiza icumba kiri ahantu ha conyene, kugira hasuzumwe indwara zo mu mutwe, iz’imitsi nsozabwenge n’iziva ku gufata ibiyayuramutwe. Igihe ata cumba kiri ukwaco coboneka, kugerageza kugabura aho hantu ukoresheje ibitambara canke ibindi bintu kugira habe hihishije. Ugutunganywa kw’ibikorwa » Hasabwa ko haboneka n’imiburiburi umuvuzi umwe w’umuhinga aseruka umwanya wose mu kuvura izo ndwara, n’ukuvuga ko umuntu arungikwa ahabera isuzumwa n’ivurwa ry’indwara zo mu mutwe, z’imitsi nsozabwenge n’iziva ku gufata ibiyayuramutwe. » Bidashobotse, ukuvurwa kw’izo ndwara kurashobora kurangurwa rimwe canke kabiri mu ndwi mu bigo vy’amagara y’abantu bivura indwara zisanzwe k’umurango aho ivyo bigo bidafise ibikorwa vyinshi. Igihe abantu baje inyuma y’amasaha yo kuvurwa kw’izo ndwara, vyoba vyiza basabwe n’ubwitonzi bwinshi ko bogaruka ku kirangaminsi gitegekanijwe. Itunganywa ry’ubwo buvuzi bw’izo ndwara rirashobora kuba nkenerwa mu bigo vy’ubuvuzi vyamana ibikorwa vyinshi, cane cane mu kugira isuzumwa ryambere muri rusangi riba rirerire kuruta ikurikirana. Abakozi hamwe n’inyigisho » Abakozi bose bogira itegeko ryo gutegura ikibanza gitekanya ku bantu barwaye indwara zo mu mutwe MNS. » Gutora abakozi boronka inyigisho z’ubuvuzi bw’indwara zo mu mutwe, iz’imitsi nsozabwenge n’iziva ku gufata ibiyayuramutwe. » Kumenya ko ivya nkenerwa bihari, atari kubw’inyigisho gusa ariko kandi kubw’ubugenduzi. Ubugenduzi bw’ubuvuzi bw’abakozi ni kimwe gikenewe mu bigize ubuvuzi ngirakamaro. » Igihe bamwe mu bakozi bashoboye kwigishwa ibiri mw’iki gitabu, birakenewe kumenya ko abandi bakozi basigaye bashobora gutanga ubufasha bwa mbere mu vy’inyifato (PSP). Ukwerekeza ku bufasha bwambere mu nyifato bitegerezwa gukorwa ikiringo kingana n’imiburiburi n’igice c’umunsi. » Kwereka uwakira abarwayi (canke uwundi wese akora ico gikorwa) uko afata abantu biyambagura bashobora gusaba ubufasha bwihuta. » Kwigisha abaremeshakiyago n’abakorerabushake, igihe biruko, kugira bashobore: (a) guhimiriza ku bijanye n’ubuvuzi bw’indwara zo mu mutwe, iz’imitsi nsozabwenge n’iziva kugufata ibiyayuramutwe (raba ibikurikira), (b) gufasha abantu barwaye izo ndwara mu kubaronderera ubufasha mu bigo vy’amagara y’abantu, (c) ukugira uruhara mu gukurikirana ubuvuzi bw’abarwaye. » Gutegekanya kwigisha hamwe no gukurikirana umwe mu murwi w’abakozi (abavuzi, uwujejwe inyifato n’imibano, umuremeshakiyago) kugira ngo atange ubufasha bw’inyifato n’imibano (akarorero, gutanga ubufasha bugufi bw’inyifato, kuyobora imigwi y’ugufashanya, kwigisha uburyo bwo kugabanya uruhagarara rwo mu mutima). » Kwigisha abakozi bose ibikoresho bihasanzwe vyo kwikingira: ◆ Ibisabwa mu bijanye n’ukwemera kuvurwa n’amategeko bijanye, cane cane gushengeza abakubagura abana, abagize ihohoterwa rifatiye ku gitsina hamwe n’ayandi makubagurwa y’agateka ka zina muntu ; ◆ Umwidondoro, ukurondera hamwe n’ukwegeranya imiryango. Abana batari mu miryango bategerezwa vy’umwihariko gukingirwa nokwerekwa ababatunganiriza muri ico gihe. » Igihe abahinga mpuzamakungu mu vy’amagara yo mu mutwe baje gukorera mu kigo, kugira bashire mu ngiro igikorwa c’ubugenduzi, bazobabwirwa umuco n’uko bimeze mukibano. » Kumenyesha abakozi bose indinganizo bokurikiza mukwitura ibisata bihasanzwe. Impanuro ku baserukira ubuvuzi 4Ibimenyeshejwe ku bisata bihari » Gutegura ubutumwa bugenewe ikibano mu vy’ubuvuzi bw’indwara zo mu mutwe, iz’imitsi nsozabwenge n’iziva kugufata ibiyayuramutwe zihari (nk’akarorero ihangiro hamwe n’akamaro k’ubuvuzi bw’izo ndwara, ibisata bihari mu kigo c’amagara y’abantu), indondoro hamwe n’amasaha bugururirako ico kigo). » Kuganira ku bijanye n’ubwo butumwa hamwe n’abatware bo mu kibano. » Gukoresha uburyo bwinshi bwo gukwiragiza ibimenyeshwa nk’iradiyo, ivyandiko bamanika mu bigo vy’amagara y’abantu, abaremeshakiyago canke ubundi buryo bwotuma bikwiragizwa mu bantu benshi. » Iyo biri uko, tegekanya kuganira kur’ubwo butumwa n’abavuzi kama hamwe n’abasangwabutaka bashobora guha ubufasha mu buvuzi bw’abantu barwaye indwara zo mu mutwe, iz’imitsi nsozabwenge n’iziva kugufata ibiyayuramutwe bipfuza gukorana canke kubereka abarwayi (bakeneye impanuro bijanye. Kwiyibutsa kukigabane ca 6.4 c’intumbero z’umurwi wamaho mpuzamashirahamwe kuvyerekeye amagara yo mumutwe n’ubufasha mu nyifato n’imibano mu gihe c’ubutabazi [CPI/IASC, 2007]). » Gushikira imigwi yakumiriwe ishobora kutamenya canke kudashika mu kigo c’ubuvuzi. Imiti » Gukorana n’abafata ingingo mu kuguma haboneka imiti y’ibanze. » Gutegekanya ukuboneka kw’imiti ikenewe n’imiburiburi : ◆ umuti uvura indwara zo mumutwe zeruye (inshinge canke ibinini) ; ◆ umuti ukosora ukujugumira n’izindi ngaruka mbi bivuye kur’iyo miti*(ibinini) ; ◆ umuti uvura ibisahuzi/intandara (ibinini) ; ◆ umuti uvura uguhagarika umutima (inshinge n’ibinini). » Ivyankenerwa mu buvuzi bw’ubutabazi hagati mu bigo (OMS, 2011) biraboneka, bigizwe n’imiti hamwe n’ibindi bikoresho vyagenewe gutorera umuti ibikenewe mu buvuzi bw’ibanze. ◆ Ivyo vyankenerwa bigizwe n’imiti yo mumutwe ikurikira : Ibinini « amitriptylline : ibinini ibihumbi bine vya mirigarama 25, kimwe kimwe Ibinini « biperdène » : ibinini amajana ane vya mirigarama 2 kimwe kimwe Umiti « diazépam » : ibinini amajana abiri na mirongo ine, mirigarama 5 kimwe kimwe Inshinge za « diazépam » : amajana abiri za miriritiro 2 canke 5, miriritiro 2 kuri « ampoule » imwe Umuti « halopéridol »: ibinini igihumbi n’amajana atatu vya mirigarama 5 kimwekimwe  Inshinge za « halopéridol » : mirongo ibiri za mirigarama 5 kuri miriritiro imwe, miriritiro 1 kuri « ampoule » imwe umuti « phénobarbital»: ibinini igihumbi vya mirigarama 50 kimwe kimwe ◆ Urugezo rw’iyo miti ntirukwiye mu bisata bisuzuma bikongera bikavura indwara z’intandara, indwara yo mu mutwe yeruye hamwe n’ukuyinga. Imiti yiyongerako itegerezwa gutumwako. ◆ Mu gihe kirekire, urugezo rukwiye rw’imiti ruzoharurwa hisunzwe ikoreshwa nyaryo ryayo. » Hejuru y’iyo miti ivura indwara zo mu mutwe, umuti witwa “atropine” utegerezwa kuba uhari mu kuvura ubumara bw’umushuhira butewe n’imiti yica udukoko, uburyo buboneka kenshi bwo kwigirira nabi. Uwo muti “atropine” urimwo mu bikoresho vy’ubuvuzi bw’ubutabazi mu bigo (inshinge mirongo itanu za mirigarama imwe kuri miriritiro imwe, buri rushing rurimwo miriritiro imwe). » Kumenya ko iyo miti yose ibitswe neza. Itunganywa ry’amakuru » Kumwemerera ukuzigama ibanga. Udutabo two kwa muganga dutegerezwa gushingurwa neza. » Kurondera ibintu bikenewe vyose kugira habe iyandikwa mugisata kijejwe ihanahanamakuru mu vy’ubuvuzi. ◆ Hasabwe gukoresha ibigize ubuvuzi bw’indwara zo mu mu mutwe, z’imitsi nsozabwenge n’izifatiye kugufata ibiyayuramutwe mu mice 7 y’igisata c’ihanahanamakuru mu vy’ubuvuzi ryatanzwe n’ishirahamwe mpuzamakungu ryitaho impunzi (UNHCR) kugira herekanwe indwara zo mu mutwe, z’imitsi nsozabwenge n’iziva kugufata ibiyayuramutwe (raba ivyongeweko vya 1). ◆ Mu bihe vy’ubutabazi bukomeye, abafat’ingingo mu vy’amagara y’abantu barashobora ku batiteguriye kwongerako iyo mice 7 mw’ihanahanamakuru mu buvuzi. Muri ico gihe, umuce bita « ingorane zo mu mutwe, iz’imitsi nsoza bwenge, hamwe n’iziterwa no gufata ibiyayuramutwe », urashobora kongerwako mu gisata c’ihanahanamakuru mu buvuzi. Izoca isubirizwa mu nyuma n’ikindi gisiguritse neza. » Kwegeranya no kwihweza ivyegeranijwe hamwe no gutanga ivyatowe ku begwa n’ugufata ingingo z’amagara y’abantu. Ukurungika – kurondera ubufasha » Kumenya ko ikigo gifise urutonde rw’amazina ruri ku gihe rwaho borungika abarwaye indwara zo mumutwe, iz’udutsi nsozabwenge n’iziva kugufata ibiyayuramutwe mu gihe bikenewe. » Kumenya neza ko ikigo gifise urutonde rw’amazina ruri kugihe rw’aho borungika abarwaye ku vyerekeye ubundi buryo bw’ubufasha mu karere (kumenya nk’akarorero ibikenewe vy’ibanze, nk’uburaro, ibifungurwa, ibisata n’ubufasha mu mibano n’imiryango, ugukinga hamwe n’ubufasha mu vy’amategeko). 5PG S Ingingo ngenderwako z’ubuvuzi bw’abagendana indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe mu bihe vy’ubutabazi PGS 1. Ingingo zo kuganira Mu bihe vy’ubutabazi, bivanye n’ihindagurika kandi rititeguriwe ry’ubufasha bwihuta, abavuzi bagira umutwaro ukomeye kugirango biteho abantu benshi bashoboka mu mwanya muto. Mu mavuriro, ugusuzuma abarwayi bitegerezwa kumara umwanya muto, mu buryo bworoshe kandi bikaba vyerekeje ku bibazo vyihutirwa cane. Ubushobozi buhagije bwo kuganira bwofasha abavuzi gushika kuri izo hangiro zo gutanga ubuvuzi ngirakamaro ku bakuze, ku miyabaga no ku bana barwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’izijanye no gufata ibiyayuramutwe. » Tunganya ikibanza gituma abantu baganira neza. ◆ Igihe bishoboka, ganirira n’uwukwituye mu kibanza ciherereye. ◆ Kwishira k’urugero rumwe n’uwukeneye ubufasha (nk’akarorero kwicara igihe nawe yicaye). ◆ Kwakira uwukwituye, ukamwidondora, ukamubarira ico ujejwe k’urugero ruhuye n’umuco w’aho hantu. ◆ Ramutsa umuntu wese ari ngaho. ◆ Baza uwukwituye ko yipfuza ko muganira arikumwe n’abamuherekeje canke abandi bantu Kiretse igihe uwukeneye ubufasha ari umwana mutoyi, saba ko muganira n’uwukeneye ubufasha gusa. Igihe yipfuje ko agumana n’abamuherekeje, ubahiriza icipfuzo ciwe. Mu gihe muganiriye n’uwukwituye wenyene, uramusaba uruhusha rwo: ∙ kubaza ibibazo abamuherekeje kugira ngo umenye nabo ico babivugako ∙ Guha uruhara abamuherekeje igihe indinganizo y’ubufasha mwayivuganye kandi mwayumvikanyeko. ◆ Kwemerera uwakwituye ko ivyo muganira vyose biguma ari ibanga kiretse wenyene atanze uruhusha, kiretse mugiwe uwo muntu canke abandi vyobageramira (ubwo butumwa bushobora guhinduka bivanye n’amategeko y’ubutungane ngenderwako mu gihugu ciwe mu bijanye no kugumya ibanga). » Guha uruhara rukwiriye uwufise ibibazo vy’amagara yo m’umutwe akwituye uko bishoboka. ◆ Naho inyifato yiwe iba yahungabanye, gerageza igihe cose kugira agumane ikibanza nyamukuru mu kiganiro. Ivyo birafatirwako kandi ku bana, urwaruka n’abageze mu za bukuru barwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayura mutwe. Ni vyiza ko badakumirwa ngo muganire n’ababaherekeje gusa. ◆ Igihe cose, kugerageza gusigurira uwukwituye ibiriko biraba (nk’akarorero mu gihe c’isuzuma ry’umubiri) n’ibiza gukorwa mu nyuma. » Tangura kumviriza. ◆ Kureka uwukwituye akavuga utamuciriyemwo. Ntivyama bishoboka iminsi yose ko abantu bari mu gahinda baganira neza. Igihe ivyo bishitse, urarindira ukanasaba insiguro zihagije. Ntaguhutagiza. ◆ Nta guhata uwakwituye kuvuga canke kwigana ibihe nseserezamutima bishobora kumuhungabanya igihe atabishaka. N’ukumumenyesha ko tuhari kugira twumvirize. ◆ Abana bashobora gukenera umwanya munini kugira ngo bumve ko bisanzuye. Gukoresha imvugo bashobora gutahura. Mu kwubaka imigenderanire n’abana, birashobora kuba ngirakamaro ko uvuga ivyo basanzwe bakunda (Ibikinisho, abagenzi, ishuri, n’ibindi). » Gukoresha imvugo yumvikana kandi irashe. ◆ Koresha imvugo umuntu amenyereye. Kwirinda gukoresha amajambo y’ubuhinga. ◆ Uruhagarara rurashobora gutuma abantu badatahura neza amakuru, bisaba ko muvuga ku kintu kimwe kimwe, kugira atahure ikivuzwe imbere yuko mutandukira igikurikira. ◆ Kuvuga muri make ukanasubiramwo ivyiyumviro nyamukuru. Birashobora kuba ngirakamaro gusaba umurwayi canke abamuherekeje kwandika ibintu nyamukuru mwashitseko. Ataruko, tanga k’uwakwituye icegeranyo canditse c’ivyiyumviro nyamukuru. » Kwerekana umutima w’ikibabarwe igihe abantu bavuze ibintu bikomeye vyababayeko (gufatwa ku nguvu, guhohoterwa canke inyifato yo kwigirira nabi). ◆ Kumwemerera ko ivyo muyaga vyose biguma hagati yanyu. ◆ Kudafata minenerwe ibishobisho vy’umuntu, gukekeza canke gutanga insiguro yawe. ◆ Tahura ko bishobora kugorana ko umuntu avuga ivyamusesereje. ◆ Igihe bikenewe ko arungikwa k’ubundi bufasha, sigura neza inzira zigiye gukurikira. Gusaba uwakwituye uruhusha rwo gusabikaniriza ivyiwe abandi bavuzi bashobora gutanga ubufasha. Nk’akarorero: Mwambariye ko umubanyi wanyu yabagiriye nabi. Ntawundi muntu nzobibarira ariko ndazi umuntu yoshobora kubafasha. Mwokwemera ko mbarira ingorane zawe uwo dukorana wo mwishirahamwe kanaka ? 6PG S » Ntucire urubanza abakwituye kubera inyifato yabo. ◆ Abafise indwara zo mu muntwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe barashobora kugira inyifato itamenyerewe. Tahura ko bishobora kuba bivuye ku ndwara yabo. Tekana wihe umwanya. Ntakubatwenga. Igihe agize inyifato itabereye (nk’akarorero kwiyambagura, gukara, gutera ubwoba), rondera ikibimuteye unamuhitishanwo inyishu. Kwikora ku bamuherekeje canke abandi mukorana kugira wubake igihe gitekanye. Igihe ahungabanye cane kandi aguma yiyambagura, birashobora kuba ngirakamaro ko apimwa imbere y’abandi kandi agaca ajanwa aho bamusuzumira. » Igihe bikenewe harifashishwa abasobanuzi. ◆ Igihe bikenewe n’ukugerageza gukorana n’abasobanuzi babinonosoye, cane cane uwo basangiye igitsina n’uwurwaye indwara zo mu mutwe, z’imitsi nsozabwenge canke zivuye ku gufata ibiyayura mutwe. Igihe atamusobanuzi yabinonosoye ahari, abandi bavuzi mukorana canke abamuherekeje barashobora gukora ico gikorwa, umurwayi abitangiye uruhusha. ◆ Igihe uwamuherekeje abaye umusobanuzi, menya ko uwakwituye ashobora kutavuga ivyamubayeko vyose. Ikindi n’uko amatati afatiye ku nyungu hagati y’uwakwituye n’uwamuherekeje ashobora kubangamira ikiganiro muriko muragiranira. Igihe bibaye intambamyi cane, tegekanya uwundi musobanuzi ku masango akurikira. ◆ Bwira umusobanuzi ko atagerezwa kubigira ibanga kandi ko asigura akoresheje insiguro y’amajambo atinjiye mu mizi kandi atongeyeko uko abibona canke abitahura. 7PG S 2. Ingingo zo gusuzuma Gusuzuma umurwayi bisaba kumenya indwara uwukwituye afise ukanatahura uko wenyene abiha insiguro. Biranakenewe kandi ko usuzuma inkomezi n’ubushobozi (akarorero: gushigikirana mu kibano) uwukwituye afise. Ayo makuru yiyongerako atuma abavuzi batanga ubufasha bubereye. Mu gihe co gusuzuma, ni ngombwa ko uguma wihweza neza uko uwakwituye ameze muri rusangi, imero yiwe, ibimenyetso mu maso hiwe herekana hamwe n’insiguro y’ibimenyetso vy’umubiri n’amajambo arakoreshwa n’uwurwaye MNS. » Kurondera kumenya icatumye umuntu akwitura. ◆ Ni igiki catumwe mutwitura uno musi ? Vyatanguye ryari ? Vyatanguye gute ? Vyabandaniye gute ? ◆ Mwiyumva gute Kubera izo ngorane mufise ? Kubwanyu vyoba biva kuki ? ◆ Izo ngorane zoba zifise ingaruka izihe ku buzima bwanyu bwa minsi yose (mu kibano, mu rugo, ku kazi, kw’ishure) ? ◆ Mwagerageje gukora iki ngo mutore inyishu y’ivyo bibazo ? Mwoba mwaragerageje gufata imiti ? Hamwe mwoba mwarayifashe ni iy’ubwoko ubuhe (yanditswe na muganga, y’ikirundi ?). Iyo miti yabafashije k’urugero urube ? » Kurondera kumenya ko mu mu ryango hari kahise k’indwara zo mu mutwe, z’imitsi yo mu bwonko canke zivuye ku gufata ibiyayuramutwe. ◆ Mwoba muzi ko mu muryamgo hari uwundi yigeze kugira ibimenyetso nkivyo canke bishusha navyo ? » Gukora ibipimo kugira umenye uko amagara y’uwabituye yifashe muri rusangi ◆ Kubaza ibibazo bishoboka bijanye n’amagara yo mu mubiri : Mwoba mumaze kugira ikibazo c’amagara kidasanzwe ? Hari umuti w’indwara kananka mwoba muriko murafata ubu ? ◆ Baza uwakwituye ko ariko arafata imiti : Muri kino gihe hari umuti babandikiye mwoba muriko murafata ? Ni umuti uwuhe? Mwoba mwawuzanye ? Muwufata gute ? ◆ Baza ko uwakwituye yoba yarigeze gufata umuti ukamugirira ingaruka mbi ku mubiri. » Rondera ibiriko bimutera uruhagarara, uburyo bwo guhangana navyo n’ubufasha buhari. ◆ Ubuzima bwanyu bwahindutse gute kuva … (kuvuga icatumye haba icago) ? ◆ Mwoba mwarabuze umuntu mukunda ? ◆ Mwumva mufise uruhagarara ku rugero rungana gute? Vyabakozeko gute ? ◆ Muri kino gihe, ni ibihe bibazo bikomeye bibahanze ? ◆ Muhangana navyo gute ku musi ku musi ? ◆ Muronka ubufasha bumeze gute ? Muraronka ubufasha bwo mu muryango, bw’abagenzi canke bw’abantu bo mu kibano ? (umuryango, ikibano, abagenzi) » Rondera kumenya ko ata nzoga canke ibiyayuramutwe vyoba bifatwa. Ibibazo bijanye n’inzoga hamwe n’ibiyayuramutwe bishobora kubonwa nkuko umenga ni ukwinjirira canke guhanga umurwayi. Ariko birakenewe cane mu gusuzuma umurwayi wo mu mutwe. Sigurira umurwayi ko ivyo bibazo bijanye n’isuzuma kandi bikabazwa adatunzwe urutoke, adasuzuguwe kandi hubahirijwe imico. ◆ Hari ibibazo bisanzwe ntegerezwa kubabaza bijanye no gusuzuma, mwoba mufata utuyoga (canke ikindi kintu gikabura gifatwa nk’ingorane mu karere) ? Igihe woba ubifata, kangahe ku musi/ku ndwi ? ◆ Mwoba mufata imuti igihe mwumva mufise uruhagara, mwahungabanye canke mufise ubwoba? Hari ikintu mufata igihe mubabaye ku mutima? Hari imiti mwoba mufata kugira musinzire? Nimba muyifata ni kangahe ku musi/ ku ndwi? Muyifata kuva ryari ? » Rondera kumenya ko atavyiyumviro canke kugeregeza kwiyahura vyoba bihari Ibibazo bijanye no kwiyahura navyo bishobora kubonwa nk’ibihungabanya umuntu ariko birakenewe cane mu gusuzuma umuntu afise ibibazo vy’amagara yo mu mutwe. Ni kugerageza kubibaza wubahirije imico yiwe kandi utamutunze agatoke. ◆ Mushobora gutangura uku: Kazoza kanyu mukitezeko iki? Iyo ata mwizero afise muri kazoza uca ubaza ibindi bibazo (>> Igicapo 1 c’ikigabane co kwiyahura SUI) nka Mwumva kubaho bibereye ? Mwoba mumaze kwiyumvira kwigirira nabi? Mwoba mumaze gutegura kwiyaka ubuzima? (>> kwiyahura SUI) » Gupima ufatiye ku bimenyetso ◆ Gitegerezwa kuba igipimo c’umubiri gifatiye ku bimenyetso, vyisunga amakuru yatanzwe mu gihe co gusuzuma indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye kugufata ibiyayuramutwe. Igihe habonetse indwara yo mu mubiri kuri urwo rwego, bisabwa ko ivurwa canke kwitura ababishoboye. » Igihe hiketswe indwara MNS, simbira kukigabane bijanye kugira isuzumwe. » Igihe uwakwituye afise afise ibimenyetso vyerekeza kundwara nyinshi MNS, ibigabane vyose bijanye nazo birisungwa. 8PG S 3. Ingingo zo gutanga ubufasha Indwara nyinshi MNS, z’imitsi nsozabwenge n’izifatiye kugufata ibiyayuramutwe ni ngendanwa, zisaba gucungerwa no gukurikiranwa igihe kirekire. Yamara, mubihe vy’ubutabazi, kubandanya imiti birashobora kugorana kuko ubuvuzi bw’indwara zo mu mutwe butama buhari canke abantu bashobora kuba barimuwe canke bazokwimurwa. Abitaho abagendana indwara MNS bafatwa nk’abantu bazwi nk’abashobora gutanga ubufasha. Bashobora gutanga ubuvuzi, gushigikira no gukurikiranira hagufi abafise izo ndwara ikiringo cose ibihe bidasanzwe bizomara. Abafasha ni abo bantu bose basangiye uruhara ku mibereho myiza y’uwurwaye indwara MNS, nk’abo mu muryango, abagenzi canke umuntu wese w’umwizigirwa. Mu gufasha umurwayi hamwe n’uwumufasha gutahura indwara MNS, indinganizo yo gutanga ubufasha hamwe n’iyo gukurikiranwa ziremerwa neza. » Kuvura indwara zo mu mutwe no mu mubiri ku barwaye indwara MNS. ◆ Guha umurwayi insiguro zijanye n’indwara afise. Igihe avyemeye izo nsiguro ziranahabwa uwukunda kumuba hagufi. ◆ Kwiga no guca irya nino amahangiro mugiye gukorerako mukanarabira hamwe ingene agiye gufashwa. Igihe avyemeye mubirabira hamwe n’uwumuba hafi kenshi. Ku ndinganizo yo gukurikiranwa yahiswemwo, ni kumuha insiguro : ∙ Ku kamaro azoronka mu muti ; ∙ Ikiringo co gufata umuti ; ∙ Akamaro ko kubahiriza ubuvuzi, cane cane mugushira mu ngiro ubufasha bujanye n’inyifato ibereye (nk’imyimenyerezo ngororamubiri) yo muhira n’ubufasha abamwegereye bashobora kumuha ; ∙ Inkurikizi zishobora guturuka ku miti ariko arafata ; ∙ Uruhara rw’iyindi mirwi yo mu kibano : Abaremeshakiyago n’abandi bantu bizigiwe bo mu kibano (>> Ingingo zo kugabanya uruhagarara no gukomeza gushigikirana mu kibano ziza gukurikira) ; ∙ Indwara wamutoye. Gukoresha imvugo y’umwizero ariko ntumwemerere ivyo utazi neza. Igihe bikenewe, kumubwira ibijanye n’uburyo bw’amafaranga bushobora gukenerwa. » Kwishura ibibazo n’imyitwarariko umurwayi hamwe n’uwumufasha bafise ku bijanye n’indinganizo yo kuvurwa. » Imbere y’uko umurwayi ataha : ◆ Kumenya neza ko umurwayi n’abamuherekeje batahura kandi bemera indinganizo yo gufashwa, (nk’akarorero kubabwira ngo basubiremwo ingingo nyamukuru z’iyo ndinganizo). ◆ Gutera intege umurwayi n’uwamuherekeje ingene bazoza baracungana n’ibimenyetso vy’indwara bakanamenya igihe bategerezwa guca bitura muganga vyihuta. ◆ Gutegekanya isango ryo gukurikiranwa. Gutunganya indinganizo yo gukurikiranwa hisunzwe igihe c’ubutabazi barimwo (nk’akarorero kwimurwa/ guhunga kw’abantu hamwe n’ihagarikwa ry’ubuzi). Igihe umurwayi afise amahirwe make yo kubandanya akurikiranirwa ngaho : ∙ Kwandika mu ncamake indinganino yo gukurikiranwa no gutera intege kugira umurwayi azoyitondane igihe cose azoba agiye kwivuza. ∙ Gutanga umwidondoro w’ayandi mavuriro ari hafi. ◆ Mu kiringo cambere amasango yo gukurikiranwa ategerezwa kuba menshi cane gushika aho ibimenyetso bitangura kugabanuka. ◆ Igihe ibimenyetso bitanguye kugabanuka, harashingwa amasango ategeranye ariko ari ku rugero rutunganijwe. ◆ Sigurira umurwayi ko ashobora kugaruka kw’ivuriro igihe cose bikenewe hagati y’isango n’irindi ( nkiyo yagize inkurikizi mbi z’imiti). » Kuri buri sango, suzuma : ◆ Akamaro imiti iriko iragira, inkurikizi mbi z’imiti, ugufata neza imiti n’uruhara rw’ubufasha bw’imibano n’inyifato. Kwemeza intambwe zose zimaze gushikwako no gutera intege ku kubandanya gukurikiza indinganizo. ◆ Uko amagara yifashe muri rusangi. Gucungera buri gihe amagara y’umubiri. ◆ Uko umuntu yitunganiriza ubuzima (nko gufungura, kwiyuhagira, impuzu) hamwe n’inyifato yiwe aho abaye. ◆ Ingorane z’imibano n’inyifato na/canke ihindagurika ry’imibereho bishobora guhungabanya ubufasha. ◆ Ivyo umurwayi n’uwumwitaho batahura canke biteze k’ubuvuzi. Gukosora ico badatahura cose. ◆ Iminsi yose suzuma ibiranga umurwayi kuko birashobora guhinduka kenshi. » Mu kiringo cose co gukurikirana umurwayi : ◆ Kuguma mubonana n’umurwayi n’uwumufasha. Bishobotse harashirwaho umuremeshakiyago canke uwundi muntu w’umwizigirwa mu kibano kugira agumize ijisho ku murwayi. Uwo muntu ashobora kuba ari uwo mu muryango. ◆ Gushiraho indinganizo igihe umurwayi atagarutse kw’isango. Kugerageza kumenya igituma atagarutse. Umuremeshakiyago canke uwundi muntu w’umwizigirwa arashobora gufasha kuranga umurwayi ( nk’akarorero mu kumugendera i muhira). Igihe bishoboka, kuraho intambamyi ihari kugira umurwayi ashobore kugaruka kw’ivuriro. ◆ Iture umuganga w’umuhinga igihe umurwayi adatora mitende. Igihe umurwayi yibungenze canke yonsa : » Irinde kwandika imiti yoshobora kugira ingaruka mbi ku mwana ari mu nda no gufasha gushikira ubuvuzi bw’imbere yo kwibaruka » Irinde kwandika imiti ishobora kugira ingaruka mbi ku kayoya/umwana w’umukenyezi yonsa. Gukurikirana umwana w’umukenyezi yonsa ari ku miti. Kugerageza korohereza gushika mu bibanza/ amahema vyagenewe abana 9PG S 4. Ingingo zo kugabanya uruhagara no gukomeza gushigikirana mu kibano Ukugabanya uruhagarara no gukomeza gushigikirana vyinjira m’ubuvuzi bw’indwara MNS mu bihe vy’ubutabazi, aho kenshi abantu barwa mu ngero zikomeye z’uruhagarara. Si uruhagara rugirwa n’abarwayi ba MNS gusa ahubwo n’urwo ababafasha bagira hamwe nabo basanzwe bitaho. Uruhagarara ruratuma indwara MNS zihasanzwe zerura. Kubera ko ugushigikirana bigabanya inkurikizi mbi z’uruhagarara, ni kubishimikirako cane. Vyongeye, gukomeza gushigikirana ni kimwe mu bihambaye vyo gukinga (>> Ingingo zo gukingira agateka kazina muntu) hamwe no guteza imbere imibereho myiza muri rusangi y’abanyagihugu bageramiwe n’ikiza. (>> Ingingo z’umwitwarariko ufatiye ku kubaho neza muri rusangi). » Tohoza ibishobora gutera uruhagara hamwe n’ugushigikirana kuhari mu kibano. ◆ Muri kino gihe, ni ikihe kintu gikomeye kibateye impungenge ? ◆ Mubigenza gute kugira muhangane n’izo mpungenge ? ◆ Ni ibintu ibihe bibazanira ituze, inguvu n’inkomezi ? ◆ Ni uwuhe muntu mubona ko bibereye ko mwoganinira ingorane zanyu ? Igihe mwumva mutameze neza, ni nde mwazambira kugira muronke ubufasha n’impanuro ? ◆ mwotubwira ingene imigenderanire n’umuryango wanyu yifashe ? Ni gute umuryango n’abagenzi banyu babashigikira canke babahungabanya ? » Rondera neza ibimenyetso vyo guhohoterwa canke kutitabwaho. ◆ Kwitondera ibimenyetso bishoboka vy’ihohoterwa rifatiye ku gitsina canke ku mubiri (harimwo n’ihohoterwa ryo mu ngo) ku bakenyezi, ku bana hamwe n’abageze mu zabukuru (nk’akarorero kuvurirana kw’amaraso ku mubiri canke ibikomere bidasiguritse, ubwoba burenze, amakenga yo kuvuga ibibazo kanaka igihe hari umuntu wo mu muryango ahari). ◆ Kwitondera ibimenyetso bishoboka vyo kutitabwaho, cane cane ku bana, abagendana ubumuga, n’abageze mu za bukuru (nk’akarorero ugufungura nabi mu muryango ufise ibifungurwa bikwiye, umwana yigunze cane). ◆ Mu gihe ibimenyetso vy’ihohoterwa no kutitabwayo vyibonekeje, ganirira n’umurwayi ahiherereye kugira umubaze ko hari ikintu kibabaje camushikiye. ◆ Igihe hiketswe ihohoterwa canke kutitabwaho : Iture ubwo nyene umugenduzi wanyu kugira muganire indinganizo y’ivyokorwa. Igihe umurwayi abitangiye uruhusha, rondera ahova ubufasha bwo gukinga mu kibano (nk’akarorero ibisata vy’ubutungane vyizewe hamwe n’inani zo gukinga). » Ufatiye ku makuru yegeranijwe, tegekanya ubuhinga bukurikira : ◆ Ugutora umuti w’ibibazo : Koresha ubuhinga bwo gutora umuti w’ibibazo kugira ufashe umurwayi guhangana n’ibituma nyamukuru bimutera uruhagarara. Igihe ibitera uruhagarara bidashobora gukurwaho canke ngo bigabanywe, ubuhinga bwo gutora umuti w’ibibazo burashobora gukoreshwa kugira higwe uburyo bwo guhangana navyo. Muri rusangi, ntagushoka utanga impanuro. Gerageza gutera intege umurwayi kugirango yitorere wenyene inyishu ziwe. Igihe uriko witaho abana n’imiyabaga, naho nyene ni ngirakamaro gusuzuma no gutorera umuti ibitera uruhagarara ku babitaho. ◆ Gukomeza ugushigikirana mu kibano : Fasha uwakwituye gutora abantu babizigirwa bo mu muryango, abagenzi n’abo mu kibano bashobora gutanga ubufasha no kwiga ingene umwe wese yobikora. Igihe uwakwituye abitangiye uruhusha, murungike kubandi bashobora kumufasha mu kibano kugira ashigikirwe. Imboneza mu kibano, abatabazi n’abandi bizigirwa mu kibano barashobora gufasha kushikana umuntu aho aronkera ubufahsa bukwiye nk’ : ∙ Ibisata bifasha canke bikingira ; ∙ Uburararo ; ∙ Imfashanyo y’ibifungurwa n’ibindi vyankenerwa ; ∙ Ibigo rusangi ; ∙ Imirwi yo gufashanya no gushigikirana ; ∙ Ibikorwa vyo kwiteza imbere n’ibindi bikorwa vy’ubuhinga ; ∙ Inyigisho ; ∙ Ibibanza vyagenewe abana canke ibindi bikorwa biteguriwe abana n’imiyabaga. Mu kurangira umuntu, ni kumuha amakuru yose agize indondoro (Ikibanza, amasaha bugururirako, inomero za terefone, n’ibindi) kandi ukamuha n’urwandiko rwemeza ko umurungitse. ◆ Kuvura uruhagarara : Kwihweza no guteza imbere uburyo bwiza bwo kuruhuka (nko kumviriza umuziki, gukora ikarashishi n’ibindi). Kwigisha uwakwituye n’abamufasha ubuhinga buhariwe kuvura uruhagara nk’imyimenyerezo yo guhema (>> Igicapo PGS2). ∙ Mu bihe bimwe bimwe urashobora kumurungika k’umuvuzi (nk’umuforoma canke uw’imibano n’inyifato) kugira bamwigishe ubwo buhinga. » Kuvura uruhagarara rw’abafasha ◆ Kubaza abafasha kuri ibi : Amakenga bafise n’umwitwarariko bifatiye kukwitaho uwufise indwara MNS mu bihe barimwo bidasanzwe ; Ingorane zigaragara bahura nazo (nk’akarorero ibibazo vy’amahera, ibibabuza umwidegemvyo wabo canke umwanya w’akaruhuko) ; Ubushobozi bwabo mu gutunganya ibikorwa vya minsi yose, nk’akazi canke kwitaba imigirwa yo mu kibano ; Uburuhe bw’umubiri bagira ; Ubufasha bw’imibano boshobora kuronka : ∙ Abandi bantu barashobora kubafasha mu gihe bidakunze ko mwitaho umurwayi (nk’akarorero igihe murwaye canke murushe cane) ? Imibereho yabo myiza y’inyifato. Igihe abafasha bameze nk’abari mugahinda canke badatekanye, suzuma ko batoba bafise indwara MNS, (nk’akarorero Kuyinga DEP, gufata ibiyayuramutse SUB). ◆ Inyuma y’isuzumwa, gerageza gutorera umuti ivyankenerwa n’ibihanze abafasha. Ivyo bishobora gutuma : Bahabwa amakuru ; Kubarungika ku mirwi no k’ubufasha bubereye bwo mu kibano ; Kuganira kwisubirizwa rishoboka ry’akanya gatoyi. Umuntu wo mu muryango canke uwundi muntu abishoboye arashobora kwitaho umurwayi vy’imfatakibanza igihe uwumufasha nyezina aruhutse canke ariko arakora ibindi bikorwa ngirakamaro ; Koresha ubuhanuzi bwo gutorera inyishu ibibazo * kandi igisha ubuhinga bwo kuvura uruhagara ; Kuvura indwara MNS zose zibonetse ku mufasha. ◆ Tahura ko kwitaho abantu barwaye MNS bitera uruhagarara ariko sigurira umufasha ko ari ngirakamaro ko abandanya abikora. Naho ivyo bigoye, abafasha bategerezwa kubahiriza agateka k’abantu bakurikirana no kubacako igihe cose bishoboka mugufata ingingo zerekeye ubuzima bwabo. 10 PG S Icapa PGS 1 : Ugukomeza gushigikirana mu kibano Hampande yo kuvura ibimenyetso vy’indwara, himiriza ibikorwa bituma gushigikirana mu muryango no mu kibano kuri buri wese, cane cane abo mukibano bakumiriwe. Ku makuru aramvuye, raba igitabu Comprendre la protection basée sur la communauté (UNHCR, 2013) (Tahura ugukinga gufatiye ku kibano) hamwe n’agatabu 5.2 k’intumbero za CPI (umurwi wamaho mpuzamashirahamwe) zerekeye amagara yo mu mutwe n’ugushigikira imibano n’inyifato mubihe vy’ubutabazi (CPI/IASC, 2007). Igicapo PSG 2 : Umwimenyerezo ngororamubiri : Ubuhinga bwo guhema bukebuke Nshaka ndabigishe ingene mwohema kugira mutume umubiri n’umushaha biruhuka. Murabanza kwimenyereza gatoyi kugira muronke neza uburusho bw’ubwo buhinga bwo guhema. Ubwo buhinga bwibanda ku guhema kuko, igihe turi muruhagarara rwo mu mutima, uguhema kuranyaruka cane kandi ntigushika neza, arivyo bituma duhagarika umutima cane. Kugira muruhuke mu mubiri mutegerezwa guhindura uguhema kwanyu. Imbere yo gutangura, tubanza kworosha umubiri wacu. Nyiganze buhobuhoro hama muce mworosha amaboko n’amaguru yanyu. Ategerezwa kuba yiyoroheje cane kandi yirekuye. Bikore buhorobuho hindukiza ibitugu vyanyu muja inyuma kandi muhindukize umutwe wanyu ku ruhande no k’urundi. Ubu naho ni mushire ukuboko kumwe kunda ukundi nako hejuru y’igikiriza canyu. Mwiyumvire ko mufise umupira munda. Mu kwinjiza impwemu muraza gupompa uwo mupira kandi inda yanyu iravyimba. Mu gusohora impwemu, murakuramwo umwuka mu mupira kandi inda yanyu ica itubanuka. Ni mundabe, mbanza ubwambere gusohora impwemu zose ziri munda yanje. [Erekana akarorero ko guhemera munda- injiza mwongere musohore impwemu ku buryo burengeje urugero.] Dutangure, ubu, gerageza muheme co kimwe na jewe. Ntimwibagire, dutangura gusohora impwemu gushika aho zose zihera, hanyuma duca tuzinjiza. Mubishoboye, gerageza kwinjiza impwemu n’amazuru muce muzisohora n’umunwa. Neza cane, ubu, intambwe ya kabiri ijanye no kugabanya umurindi wo guhema kwanyu. Mwinjiza impwemu mu misogonda itatu, muce mureka guhema ikiringo c’imisogonda ibiri, muce musohora impwemu mu misogonda itatu. Ndaharura co kimwe namwe. Murashobora guhumiriza canke mukaguma mukanura. Twagiye, injiza impwemu, 1, 2, 3. Reka guhema, 1,2. Hanyuma rekura impwemu. 1, 2, 3. Mwoba mwumvise ingene mparura bukebuke ? [Subiramwo uwu mwimenyerezo wo guhema mu kiringo kingana hafi umunota umwe.] Ni neza cane. Munyuma, igihe mwimenyereza mwenyene, ntimwisunge cane imisogonda itatu. Nimubikore uko mubishoboye kugira mugabanye uguhema kwanyu igihe mufise uruhagara rwo mu mutina. Neza, ubu, ni mwimenyereze mwenyene igihe c’umunota umwe. 11 PG S 5. Ingingo zo gukingira agateka ka zina muntu Abarwayi b’indwara MNS zikomeye barakeneye gukingirwa kuko kenshi agateka kabo karahungabanywa. Barahura kenshi n’ibibazo vyo gushobora kwitunganiriza neza ubuzima bwabo hamwe n’imiryango yabo. Kuri ivyo hiyongerako ugukumirwa mumice myinshi y’ubuzima harimwo akazi, uburaro n’ubuzima bwo mu muryango. Ugushikira imfashanyo biragabanuka. Barashobora gukubagurwa canke kutitabwaho mu muryango wabo kandi barakwa uburengazira bwo kugira uruhara rukwiye mu kibano. Bamwe muri abo bantu bafise indwara MNS zenyuje kenshi bashobora kudatahura ko bafise indwara zobatuma bakenera ubufasha n’ubuvuzi. Mu bihe vy’ubutabazi, agateka k’abantu barwaye indwara MNS arakunda guhungabana, cane cane : » Ugukumirwa mu kuronswa ivyankenerwa vy’ibanze mu kubaho nk’ibifungurwa, amazi, itunganywa ry’ibidukikije, uburaro, ibisata vy’amagara y’abantu, gukingirwa no gufashwa mu buryo bwo kubaho ; » Kubuzwa uburenganzira bwo gukora ivyo barekuriwe n’amategeko ; » Kudashikira ibisata bitorera umuti ivyankerwa vyabo vyihariye ; » Gukubagurwa bifatiye ku mubiri no kugitsina, ikoreshwa, ihohoterwa, Kutitabwaho no gufungwa bidakurikije amategeko ; » Guhebwa canke gutandukana n’umuryango mu gihe co guhunga ; » Guhebwa no kutitabwaho mu gihe yashizwe mu bitaro. Ikibabaje, uburyo bwo gukingira abantu mu kibano hamwe n’indinganizo zifatiye ku bushobozi buke si iminsi yose zishiramwo, canke zirakuramwo rimwe na rimwe, ugukingira abantu bagendana indwara MNS zikomeye. Abavuzi bategerezwa rero gukora bashimitse kugira bakureho ako gahaze mu gukingirwa kw’abo bantu. Ingingo nyamukuru zisiguwe aha musi zirondera gutuma haba ugukingirwa kw’abarwaye indwara kandi baba mu kibano mu bihe vy’ubutabazi. » Ha uruhara abo vyega nyamukuru ◆ Tohoza abafise uruhara nyamukuru bategerezwa kuronswa amakuru ku bibazo vyo gukingira abantu barwaye MNS. Abo bafise uruhara bagizwe na : Abarwaye indwara MNS hamwe n’ababafasha ; Abatware bo mu kibano (nk’akarorero abaserukira abatowe mu kibano, abakurambere, abigisha, imboneza z’amadini, abavuzi b’imiti y’ikirundi n’abasenzi) ; Abaserukira ibisata bitandukanye (cane cane ugukinga/umutekano, amagara, uburaro, amazi, itunganywa ry’ibidukikije, ugufungura, indero, indinganizo zijanye n’uburyo bwo kubaho) ; Abaserukira ibisata vy’abagendana ubumuga (ibisata vyinshi, kubera ubusamazi, ntivyitaho ubumuga buturutse ku ndwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe) ; Abaserukira imirwi yo mu kibano (urwaruka canke abakenyezi) n’amashirahamwe aharanira agateka ka zina muntu, igiporisi n’abakuru mu butungane. ◆ Gutegura ibikorwa vyo guhimiriza abafise uruhara nyamukuru : Tegekanya gutegura amanama yo guhanahana ivyiyumviro ku ndwara zo m’umutwe, z’imitsi nsozabwenge n’iziturutse kugufata ibiyayuramutwe. Suzuma abantu barwaye indwara zo m’umutwe, z’imitsi nsozabwenge n’iziturutse kugufata ibiyayuramutwe, ababafasha n’ibisata vy’ubumuga hamwe n’ibisata vy’imibano kugira hategurwe kandi hashirwe mu ngiro ibikorwa vyo guhimiriza. Mu gihe c’ibikorwa vyo guhimiriza : ∙ Menyesha kandi hagarika ivyiyumviro bibi baronse biraba abarwayi b’indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe. ∙ Menyesha agateka k’abarwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe, cane cane ukungana mu kuronswa imfashanyo no gukingirwa. ∙ Kinga ugukumirwa kw’abarwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe. ∙ Himiriza abafasha gushigikira abarwaye indwra zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe. » Mu mavuriro, kingira agateka k’abagwaye indwara zikomeye zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe. ◆ Iminsi yose vurana icubahiro n’ubuntu abagwaye indwara zikomeye zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe. ◆ Tohoza umenye neza ko abagwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe baronswa ubuvuzi bumwe n’abandi batazirwaye. ◆ Ubahiriza uburenganzira bw’umurwayi bwo kwanka ubuvuzi kiretse adafise ubushobozi bwo gufata iyo ngingo (isunge amasezerano mpuzamakungu yateweko igikumu). ◆ Guhagarika ingingo yo kumushira mu bitaro. Igihe umurwayi aba amaze gushirwa mu bitaro, muri ico gihe haranira iyubahirizwa ry’agateka kiwe. » Haranira gusubiza mu buzima bwo mu kibano abantu barwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe zikomeye. ◆ Vugira abantu barwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe ngo bashirwe mu bufasha bwo kubaho, mu ndinganizo zo gukingirwa n’ibindi bikorwa vyo mu kibano. ◆ Haranira ko abana barwaye intandara n’izindi ndwara zo mu mutwe, z’imitsi nsozabwege n’iziturutse ku gufata ibiyayuramutwe bitabwaho mu guhabwa indero kama. ◆ Haranira ishirwaho ry’imigambi ifasha abana n’abakuze bafise ubukehabwenge/ kuzingama gushirwa mu migambi y’ubufasha bwo mu kibano kubagendana ubumuga. ◆ Haranira kugumizaho uko bishoboka kose, ukwigenga no kwishira ukizana kw’abarwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe. Ingingo ngenderwako zo gukinga mu gikorwa c’ubutabazi bw’abantu zasiguwe mu gitabo Manuel Sphère (Projet Sphère, 2011). Ku makuru aramvuye ku gukingira abarwayi mu mavuriro/ ibitaro vy’abarwaye mu mutwe, raba agatabu 6.3 z’intumbero za CPI (umurwi wamaho mpuzamashirahamwe) ziraba amagara yo mu mutwe hamwe n’ugushigikirana mu mibano n’inyifato mu bihe vy’ubutabazi (CPI/IASC, 2007). 12 PG S Ibisata vy’ubuvuzi Gushigikira imibano n’inyifato Gukomeza gushigikirana mu kibano no mu muryango Ivyo mu kibano bifatirwako mu bisata vyibanze n’umutekano Uturorero : Ubuvuzi bw’amagara yo mu mutwe (bikorwa n’abakozi b’ubuvuzi bw’ibanze canke n’abahinga b’amagara yo mu mutwe) Ugushigikirwa kwambere k’uburwaneza kandi burashe ku barwaye canke ku miryango yatowe. Ugutanguza inani z’imibano Ibibanza vyagenewe abana Guharanira ingendo nziza z’ubutabazi : Ibisata vy’ibanze vyizewe, bitunganijwe neza muvyimibano kandi bikingira ubuntu. 6. Ingingo zo kwitwararika gufatiye ku mibereho myiza Iruhande y’ubuvuzi, abarwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe barakenera ubundi bufasha bwinshi kubw’imibereho myiza yabo. Ivyo ni cane cane mu gihe c’ubutabazi aho usanga ubufasha bwibanze, ibisata vy’imibano, ubuzima bwo mu muryango hamwe n’umutekano biba bidakwiye. Abarwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe bahura n’inzitizi mu gukora neza ibikorwa vyabo vyo mu buzima bwa minsi yose hamwe no kwiyitaho vyibanze. Uruhara rw’abavuzi rurarenze urwo kuvura: ruranarondera guharanira ukubaho neza muri rusangi kw’abarwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe mu bisata bitandukanye, nk’uko urukurikirane rw’intumbero rwa CPI rubitangira umuco (raba igicapo PGS 1). » Fasha abarwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe gushikira bikwiye ibisata vya nkenerwa mu kubaho no kugira uburengaznira bwo kubaho mu buntu (cane cane amazi, itunganywa ry’ibidukikije, imfashanyo y’ibifungurwa, uburaro, imfashanyo y’uburyo bwo kubaho). Ivyo bishobora gutuma haba : ◆ Gutanga amakuru ku bufasha buriho naho buherereye ; ◆ Gukorana n’inguvu n’igisata c’imibano kugira abantu bahuzwe n’ibisata vy’imibano (nk’akarorero Ubufasha bw’abo mu kibano) ; ◆ Tanga inyigisho ku bibazo vyerekeranye umutekano igihe umuntu adafise amakuru akwiye k’ukugeramirwa kw’umutekano wiwe. » Tegura ugushikira ibikorwa bitegekanijwe ku barwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’iziturutse ku gufata ibiyayuramutwe, imbere y’abandi nk’akarorero gufasha abana bazirwaye gushikira ibibanza vyabagenewe. » Kingira amagara y’umubiri muri rusangi y’abantu barwaye indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku gufata ibiyayuramutwe : ◆ Shira mu ngiro incanco n’ibipimo vy’amagara bitunganijwe. ◆ Tanga amakuru k’ubufasha bw’umuntu bwibanze (gufungura, ibikorwa ngororamubiri, kwikingira mu mibonano mpuzabitsina, gutandukanya imvyaro, n’ibindi). Igicapo PSG 1. Urukurikirane rw’ubutabazi bwa CPI kumagara yo mu mutwe n’ugushikigikirana mu mibano n’inyifato mu bihe vy’ubutabazi (vyahinyanyuwe hatanzwe uruhusha). 13 ST R Uruhagarara rw’umushuhira rwo mu mutima STR Mubihe vy’ubutabazi, abakuze, imiyabaga n’abana barahura n’ibihe bishobora kubasesereza ku mutima*. Ivyo bihe bishobora kubatera ingorane nyinshi zijanye n’ibishobisho, ubwenge, inyifato no mu mubiri. N’ubwo vyinshi mu bimenyetso bishobora kwiheza bukwi na bukwi kandi ntibivemwo indwara zo mu mutwe, abantu bafise ibimenyetso bikomeye bategerezwa kenshi na kenshi kuja kurondera ubufasha mu bigo vy’amagara y’abantu. Mu bihe vy’ubutabazi, abantu barahura n’ibihe vyinshi bishobora kuba nseserezamutima n’ukubura abantu canke ibintu ngirakamaro, bashobora rero kugirira icarimwe ibimenyetso vy’ikigandaro n’ivy’uruhagarara rw’umushuhira. Ibimenyetso, isuzuma, n’ubufasha bw’uruhagarara n’ikigandaro bifise ivyo bihurirako vyinshi. Yamara ikigandaro tugisanga mu kigabane cihariye (>> ikigandaro DEU). Inyuma yo guca mu bihe bishobora kuba nseserezamutima vya vuba, abavuzi bategerezwa kurondera ibi bintu bikurikira : » Ibimenyetso nyavyo biranga uruhagarara rw’umushuhira rwo mu mutima (STR) Abantu bafise ibi bimenyetso bashobora kwerekana urusukirane rw’indwara zo mu mubiri zidasiguritse kwa muganga hamwe n’iz’inyifato ataco zerekana. Ivyo bimenyetso bijanye n’ingorane zishobora kuba zaratewe n’ibihe nseserezamutima umurwayi aba yaraciyemwo mu kwezi guheze, kuber’ivyo abo bantu baraheza bakaja kubonana n’umuganga, canke bishobora guhungabanya ibikorwa vya minsi yose kandi bitandukanye n’ibifatirwaho ku zindi ndwara zivugwa muri kino gitabo. Iki kigabane kirimwo ukuntu ugusuzuma no kuvura ibimenyetso biranga uruhagarara rw’umushuhira rwo mu mutima. » Ihahamuka (>> ESPT) Mu gihe umurwi w’ibimenyetso nyezina (igarukagaruka ry’ivyo yaciyemwo, kwirinda gusubira ahabereye ivyo vyamusesereje n’ukwirinda kwumva uwuvuga ivyamuteye uruhagarara, ibigumbagumba vy’icago camaho) bibandanya mu kiringo kirenga ukwezi uwo muntu ahejeje gushikirwa n’ibihe nseserezamutima, canke mu gihe rutumye haba ihungabana ry’ibikorwa vya minsi yose, uwo muntu ashobora kuba yarwaye ihahamuka. » Ingorane n’indwara biboneka kenshi na kenshi inyuma yoguca mu bitera uruhagarara (nk’ibihe nseserezamutima) ariko birashobora no gushika no k’uwutahuye navyo. Harimwo indwara zikurikira : indwara yo kuyinga n’akabonge (>> DEP), indwara zo mu mutwe zeruye (>> PSY), kunywa inzoga no gufata ibiyayuramutwe bishobora kumerera nabi amagara (>> SUB), ukwiyahura (>> SUI) n’izindi ngwara zikomeye z’amagara yo mu mutwe (>> AUT). » Ibimenyetso bidashemeye kandi bidakenewe kuvurwa kwa muganga. Ivyo bimenyetso nivyo bikunze kuboneka.Harimwo ibimenyetso bimara umwanya muto bidatuma abantu bitura abavuzi kandi bidahungabanya ibikorwa vyabo vya minsi yose. Mu gihe nk’ico, abavuzi bategerezwa gushigikira, kugerageza gutora umuti ku vya nkenerwa n’imyitwarariko y’uwabituye kandi bakagenzura ko ukwikiza kwitezwe kwabaye. Module 14 ST R Gusuzuma : ikibazo : 2 : Mu gihe habaye igihe gishobora kuba nseserezamutima haraheze ukwezi, uwakwituye yoba afise ibimenyotso biranga uruhagarara ryo mu mutima rw’umushuhira ? » Rondera ibimenyetso bikurikira : ◆ Guhagarika umutima bivuye ku vyago vyatewe n’igihe nseserezamutima ◆ Ihungabana ry’itiro ◆ Ihungabana ry’ikoreshabwenge ◆ Kurota nabi vyisubiriza, igarukagaruka ry’ivyatumye ahungabana* canke kwibuka vyiyadukiza* bijanye n’igihe nseserezamutima, biherekezwa n’inyifato y’ubwoba bwinshi canke gutunguruka umutima ◆ Kwirinda nkana ivyiyumviro, ukwibuka, ibikorwa canke ibihe vyotuma asubira kwibuka ivyamubayeko (nk’akrorero, aranka kuvuga ibijanye n’ivyamubayeko canke gusubira aho ivyo bintu vyabereye) ◆ Gukara bidasanzwe, umwitwarariko udasanzwe no kwama agavye imbere y’ikintu cose canke gusanuka hari urwamo canke igikakaje atari yiteze ◆ Kurwa bukumbi, gutakaza ubwenge, kuba atakintu nakimwe ashobora kwumva ◆ Ibigumbagumba (nk’akarorero gushavura canke kurira) canke ivyiyumviro vy’umwitwarariko ◆ Ihindagurika ry’inyifato nk’ibi bikurikira : Gukara birengeje Kwigunga Inyifato ishobora gutera ingorane ku miyabaga Inyifato isubiza inyuma* irangwa n’ibimenyetso nk’ugusubira kwigirako umwanda muto, inyifato yokwigungirako canke kurizwa n’ikintu kidafashe ku bana. ◆ Guhezagirika (nk’akarorero guhemagirika canke kwumva ubura impwemu) ◆ Indwara zo mu mubiri zidasiguritse kwa muganga nk’akarorero : Kwumva indihagizi z’umutima, kuzungurirwa Kumeneka umutwe, ububabare no kuvunagurika mu mubiri Ibimenyetso vyo ku mubiri bituma umurwayi atakimenya icari naho ari (nk’akarorero ubumuga budasiguritse kwa muganga*, kudashobora kuvuga canke kubona, ibimenyetso bisa n’ibisahuzi*). » Ibimenyetso vyerekana uruhagarara rw’umushuhira rwo mu mutima bishobora kuba vyo igihe ibifatirwako bikurikira vyose biba bihari: ◆ Uwakwituye yaragize igihe gishobora kuba nseserezamutima haraheze ukwezi ; ◆ Ibimenyetso vyibonekeje inyuma y’ico gihe ; ◆ Uwakwituye aragira ingorane nyinshi zo gukora ibikorwa vya minsi yose kubera ibimenyetso canke akitura abaganga kubera vyo. » Baza ko uwakwituye yoba yarahuye n’ibihe nseserezamutima. Ibihe nseserezamutima bishobora kuba ibiteye ubwoba canke bihambaye, nk’ihohoterwa ryo ku mubiri canke bifatiye ku gitsina (tutibagiye ihohoterwa ryo mu muryango), kuba mu bugizi bwa nabi canke amasanganya, canke ibikomere bidasanzwe. Baza nk’akarorero ibibazo bikurikira : ◆ Ni ikihe gihe nseserezamutima gikomeye mwabayemwo ? ◆ Ubuzima bwanyu bwarahungabanye ? ◆ Mwarabaye mubihe biteye ubwoba vyabahungabanije ? ◆ Murumva amahoro muri iwanyu ? » Baza iminsi ihaciye igihe nseserezamutima kibaye. » Simbira ku kibazo ca 2 namba hari igihe nseserezamutima coba carashitse haciye ukwezi kurenga. » Mu gihe hoba harabaye kubura ikintu gihambaye (nko gupfisha umuntu yakundwa) suzuma kandi ibimenyetso vy’ikigandaro (>> DEU). » Hamwe igihe nseserezamutima coba carashitse mu gihe kirenze ukwezi, suzuma izindi ndwara zivugwa muri kino gitabo (ukuyinga DEP; uguhahamuka ESPT; indwara zo mu mutwe zeruye PSY, indwara zitewe no gufata ibiyayuramutwe SUB). Gusuzuma Gusuzuma : ikibazo ca:1 Uwakwituye yoba aheruka guhura vuba n’ibihe nseserezamutima ? Ugusuzuma - Ikibazo ca 3 : Hoba hari iyindi ndwara afise kiretse iyo aje kwivuza ? » Rondera indwara zo mu mubiri afise zisigura ivyo bimenyetso, igihe zibonetse zivure. » Rondera izindi ndwara zo mu mutwe, z’udutsi nsozabwenge n’izijanye no gufata ibiyayuramutwe (harimwo no kuyinga) bivugwa muri iki gitabo kandi bishobora gusigura ivyo bimenyetso. Igihe zibonetse, zivure. 15 ST R Indinganizo z’ubufasha nshimikiro 1. Mu bihe vyose : » Tanga ubufasha bw’inyifato n’imibano burushirije nkuko bivugwa mu ngingo ngenderwako zo kugabanya uruhagarara no gukomeza gushigikirana mu kibano (>> Ingingo ngenderwako z’ubuvuzi) : ◆ Hangana n’ibitera uruhagarara rw’inyifato n’imibano bihari. ◆ Komeza ugushigikirana mu kibano. ◆ Igisha ubuhinga bwo guhangana n’uruhagarara. » Menyesha uwakwituye ibimenyetso bisanzwe vy’ikigandaro n’ivy’uruhagarara rw’umushuhira rwo mu mutima, nk’akarorero : ◆ Ivyo bimenyetso biribonekeza kenshi inyuma y’ibihe nk’ivyo. ◆ Kenshi na kenshi bigenda bigabanuka uko igihe gihera. » Kuvura izindi ndwara asanganywe. 2. Mu gihe ihungabana ry’itiro ari nk’ikimenyetso c’uruhagarara rw’umushuhira rwo mu mutima, mufashe guhitamwo ubufasha bwiyongera nk’uku gukurikira : » Sigura ko ihungabana ry’itiro (kubura itiro) rishika kenshi inyuma y’ukugira uruhagarara rukomeye rwo mu mutima. » Rondera wongere uvure ibituma vy’ibidukikije bitera kubura itiro (urwamo nk’akarorero). » Rondera wongere uvure ukubura itiro bitewe n’ingorane zo mu mubiri (ububabare nk’akarorero). » Tanga impanuro kubijanye n’ugusinzira neza, nk’akamenyero k’itiro (amasaha yubahirijwe yo kuryama nayo kuvyuka) canke akamaro ko kutanywa ikawa, itabi, inzoga ku mugoroba canke imbere yo kuja kuryama. Shimika cane usigura ko inzoga zihungabanya itiro. » Kiretse mu bihe bikomeye cane ahusanga ubutabazi bw’inyifato budashoboka kandi ukubura itiro bihungabanya ibikorwa vya minsi yose, umurwayi ashobora kuja ku muti igihe gitoyi (iminsi 3 gushika ku minsi 7) ◆ Uko bayifata : K’uwukuze, mwandikire 2-5mg za « diazépam » imbere yo kuryama. Kuwugeze mu za bukuru, mwandikire 1-2,5mg za « diazépam » imbere yo kuryama. Suzuma ikorana ry’iyindi miti imbere y’ukwandika « diazépam ». Kwisinzirirako no gucika intege biri mubimenyetso bikunze kuboneka vy’ingaruka mbi z’imiti iri mu murwi « benzodiazépines ». Menya neza : imiti y’itiro « benzodiazépines » ishobora kugabanya umurindi wo guhema. Harakenewe ikurikirana ku rugero rutegekanijwe. Menya neza : imiti y’itiro « benzodiazépines » n’ukuyikoresha mu kiringo gitoyi ahandi ho ishobora gutera ukwizizirwa nayo no kwama ayifata*. Ni kuyikoresha ikiringo gito. ◆ Kugabisha : Uwo muti ugenewe abakuze. Kirazira kwandikira imiti « benzodiazépines » ku bana n’imiyabaga. Irinde gutanga uwo muti ku bakenyezi bibungenze canke bonsa. Cungera kenshi na kenshi ibimenyetso vy’ingaruka mbi mu gihe wandikiye uwo muti abantu bageze mu za bukuru. Imiti « benzodiazépines » n’inyishu y’igihe gito kw’ihungabana rikomeye ry’itiro. Ntitegerezwa gukoreshwa ku kubura itiro bivuye ku kigandaro ku wukuze canke ku mwana. Ntitegerezwa gukoreshwa ku bindi bimenyetso kiretse mu ruhagarara rwo mu mutima rw’umushuhira canke ihahamuka ESPT. 3 Ubuhinga busiguwe NGAHA akenshi bwitwa ubutabazi bw’ibanze bw’inyifato igihe bukireshejwe ubwo nyene inyuma y’igihe gitera uruhagarara rukomeye (>> OMS, WTF et WVI, 2013). » Tanga ubufasha bw’inyifato n’imibano nshimikiro3 ◆ Umviriza neza. NTUHATIRE uwakwituye kuvuga. ◆ Baza uwakwituye ku vya nkenerwa n’imyitwarariko vyiwe. ◆ Fasha uwakwituye gutunganya ivyankenerwa vy’ibanze, gushikira ubufasha bwabigenewe no kwegera umuryango wiwe hamwe n’ubundi bufasha bwo gushigikirana mu kibano. ◆ Kingira uwakwituye kuri ico cose cohakwa kumumerera nabi. NTA KWANDIKA IMITI kugira uvure ibimenyetso vy’uruhagarara rwo mu mutima rw’umushuhira (kiretse mu bihe vyihariye bikurikira). 16 ST R 3. Mu gihe umwana yigirako umwanda muto nk’ikimenyetso c’uruhagarara rw’umushuhira rwo mu mutima, fasha guhitamwo ubufasha bwiyongerako bukurikira : » Rondera muri kahise kiwe kwigirako umwanda muto kugira umenye ko ivyo bitaje inyuma y’ibihe nseserezamutima. Rondera wongere uvure ibindi bituma bishoboka (ubwandu bwo mu mwanda muto nk’akarorero). » Sigura : ◆ Kwigirako umwanda muto ni ikimenyetso kimenyerewe kandi gisanzwe ku bana bahuye n’ibihe vy’uruhagarara. ◆ Abana ntibategerezwa guhanwa kubera kwigirako umwanda muto kuko igihano gisongera isibe uruhagarara nseserezamutima rw’umwana kandi kigakomeza ingorane. Umufasha ategerezwa kwirinda kwararaza ukwigirako umwanda muto kw’umwana. ◆ Abafasha bategerezwa kuguma batekanye no gushigikira umwana mu bijanye n’inyifato. » Tegekanya kwigisha abafasha kugira bagire inyifato isanzwe (nk’akarorero, kumutera intege kubona yashoboye kugabanya ivyo anywa imbere yo kuja kuryama, kuja mu kazu ka surw’umwe imbere yo kuryama, kumutera intege kumajoro amara atigizeko umwanda muto) Agashimwe gashobora kuba ico cose umwana akunda nko kumwongera umwanya wo gukina, canke kumukeza. 4. Mu gihe co guhezagirika (guhema birenze urugero kandi unyarutsa udafisemwo uruhara) nk’ibimenyetso vy’uruhagarara rw’umushuhira rwo mu mutima, tanga ubufasha bwiyongeyeko bukurikira : » Rondera wongere uvure ibindi bishobora gutera izo ngorane, naho iryo hemagirika ryoba ryatanguye ubwonyene inyuma y’ibihe nseserezamutima. Kora ibipimo vyo kwa muganga igihe cose kugira haronderwe ibituma bishoboka vyo mu mubiri nk’indwara zo mu mahaha. » Igihe ata gituma na kimwe co mu mubiri kibonetse, humuriza uwakwituye mu kumusigurira ko guhemagirika bishobora kuza inyuma y’uruhagarara rurengeje kandi ko vy’ukuri atari ingorane yo kwa muganga itangirwa umuti. » Guma utekanye hama ugerageze gukuraho ibitera guhagarika umutima. Fasha uwakwituye gusubira guhema neza ukoresheje ubuhinga bwo guhema bukebuke (>> Ingingo zo kugabanya uruhagarara no gukomeza gushigikirana mu kibano mu ngingo ngenderwako z’ubuvuzi) (nta gutekeha guhemera mugasaho). 5. Mu gihe c’ibimenyetso vyo ku mubiri bidasiguritse ufatiye k’ubuvuzi busanzwe (nk’akarorero imugara ridasiguritse kwa muganga, kudashobora kuvuga canke kubona, ibigomba gusa n’ibisahuzi) nk’ikimenyetso c’uruhagarara rw’umushuhira rwo mu mutima, tanga ubufasha bwiyongeyeko bukurikira : » Rondera wongere uvure ibindi bituma bishoboka, naho ibimenyetso vyoba vyatanguye ubwo nyene inyuma y’ibihe nseserezamutima.Mubwirizwa gukoresha ibipimo vyo kwa muganga igihe cose kugira murondere ibituma bishoboka vy’indwara zo mu mu mubiri. Raba ikigabane kivuga ivy’intandara kugira hamenyekane vyinshi ku bipimo vyo kwa muganga bifatiye ku bisahuzi (>> EPI). » Tahura ububabare bw’uwakwituye wongere ugumane inyifato ibereye. Irinde gukomeza akarusho yoronka kubera ibimenyetso afise. » Baza uwakwituye uko atahura ibimenyetso vyiwe hama ukurikize impanuro nyamukuru ku kuvura indwara zo mu mubiri zidasiguritse kwa muganga (>> AUT). » Humuriza uwakwituye mu kumusigurira ko ivyo bimenyetso biza rimwe na rimwe inyuma y’uruhagara rukomeye kandi ko muri rusangi atari ikibazo co kwa muganga. » Tegekanya gukoresha ubutabazi bwihariye bujanye n’imico y’aho hantu kandi idahohotera. 6. Bwiriza uwakwituye kugaruka mundwi 2 canke 4 mu gihe atoba yatoye mitende canke mu gihe yokwumva aguma aremba. 17 D EU Ikigandaro DEU Mu bihe vy’ubutabazi, abakuze, imiyabaga n’abana barashobora guhura n’ukubura gukomeye. Ikigandaro ni umubabaro w’ibigumbagumba abantu bagira inyuma yo kubura ivyabo. Nubwo vyinshi mu bimenyetso vyo kubura bishobora kwiheza bukwi na bukwi kandi ntibivemwo indwara zo mu mutwe, abantu bafise ibimenyetso bikomeye vy’ikigandaro, kenshi na kenshi bategerezwa kuja kurondera ubufasha mu bigo vy’amagara y’abantu. Inyuma y’ukubura, abavuzi bategerezwa kumenya gutora ibimeyetso bikurikira : » Ibimenyetso biranga ikigandaro (DEU). Nk’uko biboneka mu bimenyetso vy’uruhagarara rw’umushuhira rwo mu mutima, abantu bari mu bihe vy’ikigandaro, barashobora kugaragaza urusukirane rw’ibimenyetso vyo mu mubiri bidasiguritse kwa muganga hamwe n’ivy’inyifato, ikigandaro kitiharije. Abantu bafise ibimenyetso biranga ikigandaro inyuma yo gutakaza ivyabo mu gihe ivyo bimenyetso bibatera ingorane mu gukora imirimo ya minsi yose (birengeye ivyemewe n’umuco) canke igihe bano bantu barondeye ubufasha kugira bashobore guhangana navyo. Kino kigabane cerekana ugusuzuma no kuvura ibimenyetso bigaragaza ikigandaro. » Ikigandaro kidasanzwe. Bivuye ku kigandaro, iyo ibimenyetso biranga ikigandaro bigumyeho mu gihe kirekire, abantu barashobora kugaragaza indwara y’ikigandaro kidasanzwe. Iyo ndwara irangwa na : 1) umwitwarariko urengeje canke ugukumbura cane uwiwe yashengeye bikajana n’umubabaro urengeje w’ibishobisho, 2) ingorane ikomeye mu kurangura ibikorwa vyiwe vya minsi yose, 3) ikiringo c’amezi atandatu n’imiburiburi (Muri rusangi, iyo ico kiringo kibaye kirekire gusumba icemewe n’umuco). Muri ico gihe, abavuzi bategerezwa guca bitura umuhinga. » Ingorane n’indwara zibonekeza kenshi inyuma yo guca mu bihe vy’uruhagarara (nko gupfisha) ariko zibonekeza n’iyo uba utaciye muri mwen’ivyo bihe. Harimwo izi ndwara zikurikira : kuyinga n’akabonge (>> DEP), indwara yo mu mutwe yenyuje (>> PSY) ; ukunywa inzoga n’ibiyayuramutwe ku rugero rushobora kubangamira amagara (>> SUB), kwiyahura (>> SUI) hamwe nizindi ndwara zikomeye zo mu mutwe (>> AUT). » Ibimenyetso bidashemeye kandi bidakenewe kuvurwa kwa muganga. Ivyo bimenyetso nivyo bikunze kuboneka. Harimwo ibimenyetso bimara umwanya muto bidatuma abantu bitura abavuzi kandi bidahungabanya ibikorwa vya minsi yose birenga ku vyemewe n’umuco wabo. Mu gihe nk’ico, abavuzi bategerezwa gushigikira, kugerageza gutora umuti ku vyankenerwa n’imyitwarariko y’uwabituye kandi bakagenzura ko ukwikiza kwitezwe kwabaye, ivyo bimenyetso ntibikenera na gato ubuvuzi bwo kwa muganga. 18 D EU Ugusuzuma - Ikibazo ca 2: Mu gihe habaye ukubura gukomeye mu mezi 6 aheze4, mbega uwakwituye arafise ibimenyetso biranga ikigandaro ? » Rondera ibimenyetso bikurikira : ◆ Umubabaro, uguharika umutima, ishavu, ukwihebura ◆ Gukumbura no kugira umwitwarariko bifatiye ku kubura ◆ Ivyiyumviro vyitamwo*, amasanamu yuwashengeye n’ivyiyumviro vyerekeza kuri we ◆ Gutakaza akayabagu ◆ Gucika intege ◆ Ihungaba ry’itiro ◆ Kudendebukigwa ◆ Kwigunga no kuja kure y’abandi ◆ Indwara zo mu mubiri zidasiguritse kwa muganga (gusimbagurika umutima, kumeneka umutwe, kubabara, kuvunagurika) ◆ Ibimenyetso vy’ikigandaro bijanye n’umuco (nko kwumva ijwi ry’umuhisi canke kumubona mu ndoto). » Ibimenyetso biranga ikigandaro biba bihari igihe ibifatirwako bikurikira vyose biba bihari : ◆ Kubura rimwe canke incuro nyinshi nko mu mezi atandatu aheze ◆ Kimwe muri ivyo bimenyetso vyavuzwe aho haruguru catanguye inyuma yo kubura ◆ Ingorane zikomeye mu kurangura ibikorwa vya minsi yose kubera ibimenyetso afise (birushiriza ivyemewe n’imico) canke kwivuza ku vyerekeranye nivyo bimenyetso. Isuzuma- Ikibazo ca 3 : Hoba hari iyindi ndwara afise kiretse iyo aje kwivuza ? » Baza niba uwo muntu yoba yarabuze bikomeye. Nk’akarorero, ibibazo wobaza ni ibi bikurikira : ◆ Ni k’uruhe rugezo woba warababajwe n’ikiza hamwe n’amatati vyabaye ? ◆ Hari abantu bo mu muryango canke abagenzi mwoba mwarabuze ? Inzu yanyu ? Amahera yanyu ? Akazi canke uburyo bwahora bubatunze ? Ikibano canyu ? ◆ Ni kuruhe rugezo ukwo kubura vyoba vyarabakozeko ? ◆ Hari abantu bo mu muryango canke abagenzi boba barazimiye ? » Baza igihe kihaciye kuva ivyo bibaye ? » Simbira ku kibazo kigira 2 mu gihe ibura rikomeye ryoba ryarabaye mu mezi atandatu aheze. » Hamwe ibura rikomeye ryoba ryarabaye haraheze amezi 6 canke igihe gishobora kuba nseserezamutima coba carashitse haraheze ukwezi kurenga, suzuma izindi ndwara zivugwa muri kino gitabo (>> ukuyinga DEP, ihahamuka ESPT, indwara zo mu mutwe zenyuje PSY, gufata inzoga n’ibiyayuramutwe bibangamira amagara y’abantu SUB) canke ikigandaro kidasanzwe. Ugusuzuma Ugusuzuma - Ikibazo ca 1 : Mbega uwakwituye yoba yarabuze bikomeye mu minsi iheze ? 4 Ico kiringo kirashobora kurenza amezi atandatu mu mico ikigandaro kimara ico gihe » Rondera izindi ndwara zo mu mubiri zishobora gusigura ivyo bimenyetso, igihe zibonetse, zivure. » Suzuma izindi ndwara zose zo mu mutwe, iz’imitsi nsozabwenge canke izijanye no gufata ibiyayuramutwe (harimwo kuyinga) zivugwa muri kino gitabu kandi zishobora gusigura ivyo bimenyetso. Igihe zibonetse, zivure . 19 D EU Indinganizo y’ubufasha nshimikiro 1. Tanga ubufasha bw’imibano n’inyifato nshimikiro5 » Fasha uwakwituye gutunganya ivyankenerwa vy’ibanze, gushikira ubufasha bwabigenewe, no kwegera umuryango wiwe hamwe n’ubundi bufasha bwo gushigikirana mu kibano. » Kingira uwakwituye icomugirira nabi cose (ciyongeye). 2. Tanga ubufasha bw’inyifato n’imibano nk’uko bivugwa mu ngingo ngenderwako zo kugabanya uruhagarara hamwe no gukomeza gushigikirana mu kibano (>> Ingingo ngenderwako z’ubuvuzi). » Hangana n’ibitera uruhagarara rw’inyifato n’imibano bihari. » Komeza gushigikirana mu kibano. » Kwigisha ubuhinga bwo guhangana n’uruhagarara. 3. Menyesha uwakwituye ibimenyetso bisanzwe bifatiye ku kubura, nk’akarorero : » Baza ko imigirwa/imanza bijanye no kubura vyabaye canke ko bitegekanijwe. Bitameze uko, rabira hamwe inzitizi n’ingene zokurwaho. » Rondera ibijanye n’ikiziga. Namba ikiziga kitigeze gitorwa, fasha mu kukironka canke kuronka ibisigarira vyaco. » Namba umuvyimba udashobora gutorwa, tegekanya uburyo bwotuma haguma kwibuka nko gushiraho icibutso. 5 Ubuhinga busiguwe hano akenshi babwita ubutabazi bwa mbere bw’inyifato mu gihe bukoreshejwe ubwo nyene inyuma y’ibihe bikomeye vy’uruhagarara gukomeye (>> OMS, WTF et WVI, 2013). » Kwumviriza neza. NTUHATIRE umuntu kuvuga. » Baza uwakwituye ivyankenerwa hamwe n’umwitwarariko vyiwe. » Umwe wese yifata ugutandukanye inyuma yo kubura bikomeye. Bamwe barerekana cane ibigumbagumba, abandi ntibabigaragaze. » Kurira ntibisigura ko muri abanyantegenke. » Abatarira barashobora kuba bafise umubabaro ungana n’uw’abarira muga bobo bawugaragaza ukundi . » Murashobora kwibaza ko umubabaro n’ububabare mwumva bitazohera ariko, akenshi ivyo bigumbagumba biragabanuka uko umwanya ugenda urahera. » Murashobora kuba mumerewe neza hama hakaba ikintu kibibutsa kwa kubura, mugaca musubira kugira bwa bubabare mwari mwarigeze kugira ubwa mbere. Ivyo vyose ni ibisanzwe kandi twobahumuriza ko ivyo bigumbagumba bitera bigabanuka bikagenda biba bike uko umwanya uhera. » Nta buryo bwiza canke bubi bwo guca muri ivyo bibazo. Rimwe na rimwe, murumva mubabaye cane mu wundi mwanya mukumva mwoshobora kunezerererwa kubaho. Ntimuze mwiyagirize ku vyerekeye uko mwiyumva. 4. Kuvura izindi ndwara asanzwe afise uretse iyo aje kwivuza. 5. Ganira ku kungene mwotumbereza ikigandaro* mwisunze imico kandi mufashe uwabituye ku kungene ivyo vyogenda. 6. Igihe ivyo bishoboka kandi bijanye n’umuco w’aho abaye, himiriza gusubira ku mirimo vuba (nk’akarorero, kw’ishure, ku kazi, muhira canke mu kibano). 7. Mu kuvura vyiharije ihungabana ry’itiro, kwigirako umwanda muto, guhezagirika canke ibimenyetso bitajanye kandi bitagira n’insiguro bivuye ku kubura kwa vuba, raba ibice bijanye mu ki gabane c’uruhagarara rw’umushuhira rwo mu mutima (>> STR). NTA kwandika imiti mu kuvura ibimenyetso vy’ikigandaro 20 D EU 8. Iyo uwo muntu ari umwana mutoyi : » Ishura ku bibazo vy’uwo mwana mu gutanga insiguro zumvikana kandi z’ukuri, zijanye n’urugero rwo gutahura rw’umwana. Nta kubesha ku bibazo vyerekeye kubura (nk’akarorero, mawe wanje ari hehe ?). Ivyo bizana ukuzazanirwa bigatuma ukwizera umuvuzi bitosekara. » Rondera kandi uhanagure « ivyiyumviro bitagira mvura» bishoboka, bikunda kuboneka ku bana (umwana arashobora kwibaza ko ari we yateye ukubura, canke ko uwo akunda yashengeye kubera inyifato mbi yiwe canke ko iyo ncuti yari yamushavuriye). 9. Ku bana, imiyabaga hamwe n’abandi ba nyantege nke babuze abavyeyi canke abandi bafasha, tora umuti ku vyankenerwa vyo gukingirwa n’ubuvuzi bwamaho harimwo ugushigikira imigenderanire n’ubugwaneza. » Bibaye ngombwa, rungika uwakwituye mu mashirahamwe/inani zo gukinga zizewe. 10. Mu gihe hiketswe ikigandaro kidasanzwe, ni ukwitura umuhinga kugira ngo amusuzume yongere amuvure ku gwego rwo hejuru. Ico kiringo kirashobora kurenza amezi atandatu mu mico yemera ko ikigandaro gishobora kurenza ico kiringo. 6 Ico kiringo kirashobora kurenza amezi atandatu mu mico ikigandaro kimara ico gihe. » Umuntu arashobora kugira ikigandaro kidasanzwe mu gihe ibimenyetso vy’ikigandaro birimwo umwitwarariko udasanzwe na /canke ugukumbura cane uwiwe yashengeye, bikajana n’intuntu nyinshi hamwe n’ingorane ikomeye mu gukora ibikorwa vya minsi yose mu kiringo kingana n’amezi atandatu n’imiburiburi6. 11. Bwiriza uwakwituye kugaruka mu ndwi zibiri canke zine mu gihe atobayatoye mitende canke mu gihe yokwumva aguma aremba. 21 D EP Ukuyinga n’akabonge DEP Indwara y’ukuyinga irashobora kugaragara ku bantu bakuze, imiyabaga n’abana batigeze bahura n’ikintu kibahungabanya. Mu mibano yose, abantu barayirwara. Ariko, ukubura hamwe n’uruhagarara rukomeye mu bihe vy’ubutabazi bwihutirwa, birashobora gutera ikigandaro, ubwoba, ukwiyagiriza, isoni, n’ukwihebura vyunyura gushobora kugwara ukuyinga n’akabonge. Mugabo, ivyo bishobisho birashobora kudatera indwara bikaguma ari ibimenyetso bisanzwe bishikira abantu bahuye n’ivyago. Ivurwa ry’indwara y’ukuyinga n’akabonge ribwirizwa gutegekanywa gusa iyo umuntu afise ibimenyetso bigumaho indwi nyinshi, kandi bikaba bihungabanya cane ibikorwa vyiwe vya minsi yose. Ibituma nyezina umuntu aja kwivuza indwara y’ukuyinga n’akabonge : Gucika intege, uburuhe, ihungabana ry’itiro Ibimenyetso bitandukanye bifatira mu mubiri bigumaho ariko ata kibitera kiboneka (ububabare, ukuvunagurika mu mubiri, nk’akarorero), Umubabaro wamaho n’imero ijonjogoye, uguhagarika umutima Kubura ugushaka canke umunezero ku gikorwa icarico cose 22 D EP Ugusuzuma Ugusuzuma - Ikibazo ca 1 : Uwakwituye yoba afise indwara y’ukuyinga n’akabonge ? Ugusuzuma - ikibazo ca 3 : hoba hariho iyindi ndwara yo mu mutwe, y’imitsi nsozabwenge canke ivuye kugufata ibiyayuramutwe asanganywe ikeneye kuvurwa ? » Gusuzuma ibi bikurikira7 : A. Uwakwituye yoba afise ikimenyetso kimwe mu bimenyetso nshimikiro vy’indwara y’akabonge ikiringo kingana canke gisumba indwi zibiri : ◆ Imero ijonjogoye yamaho Ku mwana n’umuyabaga : ubukazi canke imero ijonjogoye ◆ Igabanuka rigaragara ry’ugushaka gukora canke ry’umunezero mu bikorwa vyose, harimwo n’ivyo yahora ashima Kur’iki canyuma, harimwo n’igabanuka ry’ugushaka kurangura imibonano mpuzabitsina. B. Uyo muntu yaragize ibimenyetso vyinshi muri ibi bikurikira vy’indwara y’akabonge kurugero rugaragara (canke vyinshi muri ibi bimenyetso bikurikira ku rugero ruto) ikiringo kingana n’imiburiburi n’indwi zibiri : ◆ Itiro rihungabanye canke ryinshi ◆ Ihindagurika ry’urugero rw’akayabagu canke ibiro (bike canke vyinshi) ◆ Kwumva ko ataco umaze canke kwiyagiriza birenze ◆ Uburuhe canke ugucika intege ◆ Ihungabana ry’ubushobozi bwo kwiyumvira no kugaba ◆ Ukudashobora gufata ingingo ◆ Ukwiyambagura canke ubukare bigaragara ◆ Ukwikwega mu mvugo no mubikorwa ugereranije n’uko vyahora ◆ Ukubura icizere ca kazoza ◆ Ivyiyumviro canke ukugerageza kwiyahura. C. Uyo muntu aragira ingorane zidasanzwe mu kurangura imirimo yiwe ya minsi yose, imirimo yo mu rugo, mu kibano, kw’ishure, mu kazi canke ibindi. » Iyo ibi bihe bitatu A, B, C biboneka kukiringo kingana n’indwi 2 n’imiburiburi, biragaragara neza ko uyo muntu aba arwaye indwara y’ukuyinga n’akabonge. Ukubona ibintu uko bitari*, kubona canke kwumva ibintu bitariho* birashobora kwibonekeza. Rondera ivyo bimenyetso. Iyo bihari, mukuvura iyo ndwara, ivyo bimenyetso bibwirizwa kwisungwa. Iture umuhinga. » Iyo ibimenyetso vy’uwakwituye bidahuye n’indwara y’ukuyinga n’akabonge, ronderera mu murwi w’Izindi ndwara >> AUT kugira muvure ibimenyetso vyatumye aza kwivuza. Ugusuzuma - Ikibazo ca 2 : hoba hariho izindi nsiguro zishoboka z’ivyo bimenyetso (uretse indwara y’ukuyinga n’akabonge) ? » Rondera indwara zo mu mubiri zinyegeje inyuma zigomba gusa n’indwara y’ukuyinga. ◆ Rondera wongere uvure ugukama amaraso, indwara ziva kugufungura nabi, ugukora buke buke kw’agace tiroyide*, indwara z’imitsi itembereza amaraso mu bwonko canke ingaruka mbi z’imiti (nk’ ihindagurika ry’imero ivuye kumiti bita « stéroïdes* » nk’akarorero). » Rondera muri kahise indwara y’imero y’umunezero ndenzarugero. ◆ Rondera ko muri kahise ibimenyetso vyinshi bikurikira vyabaye agasakisaki : Igabanuka ryo gushaka itiro Umunezero ndenzarugero canke ubukazi ivyiyumviro binyuragirana, gusamara vyoroshe kugira umwete urenze, kumva inguvu nyinshi, kunyarutsa kuvuga inyifato zitabereye : kutabanza kwiyumvira imbere yo gukora, ubukazi mu nkino, gufata ingingo zitateguwe, ubwibone. ◆ Suzuma urugero ivyo bimenyetso bihungabanya imirimo canke bishira uwo muntu kibure abandi mu kaga. Nk’akarorero : Ugukora birengeje kwanyu vyoba ari ingorane kuri mwebwe canke ku muryango wanyu ? Hoba hari umuntu yagerageje kubashira mu bitaro canke kubugarana kubera inyifato yanyu ? ◆ Haba hari kahise k’indwara y’umunezero ndenzarugero iyo ibimenyetso bikurikira vyabaye : Ibimenyetso bine muri bitandatu vyavuzwe aha hejuru vyaragaragaye ikiringo kirenza indwi imwe. Ibimenyetso vyarahungabanije cane imirimo ya buri munsi canke vyarashize mu kaga uyo muntu canke abandi. ◆ Iyo indwara y’umunezero ndenzarugero yamaze kuba, indwara y’agahinda iragaragaza ko hari iyindi ndwara bita indwara y’imero zibiri zidasa*, bica bituma kuyivura bihinduka (>> icapa ukuyinga n’akabonge 2 mu mpera z’iki kigabane ». » Rondera ibimenyetso bisanzwe bivuye ku kubura bikomeye (nk’urupfu, kwimurwa) « Ikigandaro DEU ». ◆ Ikimenyetso gisanzwe co kubura bikomeye kigaragara igihe : Ukworoherwa bigaragara bigenda biba uko iminsi igenda atabufasha bwo kwa muganga bubanje kuba ; Ntakimenyetso na kimwe muri ibi bikurikira kiboneka : ∙ kwiyumvamwo ko ataco umaze ∙ Ivyiyumviro vyo kwiyahura ∙ Ukwikwega cane mukuvuga no mu kwiyunguruza kuruta uko vyahora  ∙ Ibimenyetso vy’indwara zo mu mutwe zenyuje (ukubona ikintu ukutariko canke kubona no kwumva ibitariho). Nta ndwara y’ukuyinga canke y’umunezero ndenzarugero yigeze agira muri kahise ; Ibimenyetso ntibihungabanya bikomeye imirimo ya buri munsi. ∙ Kiretse : ihungabana ry’ibikorwa rishobora gufatwa nk’inyishu isanzwe y’ukubura mu mico imwe imwe. » Rondera ikigandaro kidasanzwe gifise ibi bimenyetso : umwitwarariko munini, hamwe no gukumbura uwawe bijanye n’umubabaro ndenzarugero, ikibazo gikomeye mu kurangura imirimo ya buri munsi kukiringo kingana n’imiburiburi amezi atandatu (kandi ku kiringo gisumba kure igisanzwe cemewe mu mico y’uwo muntu). Kwitura abahinga babinonosoye iyo iyo ndwara yikanzwe. » Gusuzuma ivyiyumviro n’umugambi wo kwigirira nabi canke kwiyahura (>> SUI). » Gusuzuma ukunywa inzoga canke ugufata ibiyayuramutwe bishobora kugirira nabi amagara y’umuntu (>> SUB). » Iyo hari iyindi ndwara asanganywe ibonetse, yivure hamwe n’indwara y ‘ukuyinga n’akabonge. 7 Iryo dondorwa ry’indwara y’ukuyika n’akabonye rijanye n’ibishikirizwa n’igisata kijanye no gutanga urutonde rw’indwara (CIM-11) 23 D EP Indinganizo z’ubufasha nshimikiro 1. Gutanga inyigisho. Ubufasha mu mibano no mu nyifato ◆ N’aho bigoye, umuntu abwirizwa kugerageza gukora uko bishoboka ibikorwa bikurikira kuko bishobora gufasha guteza imbere imero : Kugerageza gusubira gutangura (canke kubandanya) imirimo yahora akora imuhimbara. Kugerageza kugumana indinganizo itunganijwe yo kuryama no kuvyuka. Kugerageza uko bishoboka kwose kuguma akoresha umubiri. Kugerageza gufungura ku gihe naho hari ihindagurika ry’akayabagu. Kugerageza kugumana n’abantu bo mu muryango hamwe n’abagenzi b’abizigirwa. Kugerageza uko bishoboka kwose kugira uruhara mu bikorwa vyo mu kibano, hamwe n’ibindi bikorwa vy’imigenderanire. ◆ Umuntu abwirizwa gutegera neza ivyiyumviro vyiwe vyo kwigirira nabi n’ukwiyahura. Iyo agumana ivyiyumviro nk’ivyo ntabwirizwa gukora ico bimutegeka ahubwo kwitura umuntu w’umwizigirwa hanyuma agasubira kwivuza ubwo nyene. 2. Tanga ubufasha bw’inyifato n’imibano bwiyongeyeko nk’uko bivugwa mu ngingo zo kugabanya uruhagarara no gukomeza ubufasha mu bibano (>> Ingingo ngenderwako z’ubuvuzi) » Kwitwararrika ibitera ihungabana mu mico n’imibano bihasanzwe. » Komeza ubufasha mu kibano. ◆ Gerageza gukabura inani z’imibano z’uwo muntu zihasanzwe. Rondera ibikorwa vy’imibano vyahahora iyo bisubiriye gukorwa bishobora kuzana ubufasha mu mibano bumugana canke buciye kubandi, (nk’akarorero amanama y’umuryango, kugendera ababanyi, ibikorwa vyo mu kibano). » Igisha ubuhinga bwo guhangana n’uruhagarara. 3. Igihe abavuzi babinonosoye kandi babishoboye bahari, tegekanya guhimiriza abantu barwaye ukuyinga n’akabonge gukoresha kimwe mu buvuzi bw’imibano bukurikira, iyo buhari : » Gufasha umuntu gutora umuti w’ingorane ziwe*. » Ubufasha bufatiye ku kiganiro hagati y’umuntu n’uyundi (TIP)*. » Ubufasha bufatiye ku guhindura ivyiyumviro n’inyifato (TCC). » Ugukabura inyifato*. Kenshi na kenshi biramaze kuboneka ko ubufasha bugufi bw’inyifato ku ndwara y’ukuyinga bushobora gukorwa n’abaremeshakiyago atari abavuzi babinonosoye kandi bagenzurwa. » Ubutumwa nyezina bwagenewe umurwayi n’abafasha : ◆ Ukuyinga ni indwara ikunze kuboneka ishobora gufata umuntu uwariwe wese. ◆ Kurwara ukuyinga ntibisigura ko uba ufise intege nke canke ko uri ikinebwe. ◆ Inyifato mbi z’abandi (nka « wabwirizwa kubirengera », « isubireko ») zishobora kuva kukubera indwara yo kuyinga itagaragara (nk’invune, canke igikomere) kandi ku ciyumviro kitarico ko abantu bashobora kugenzura vyoroshe ukuyinga ku gushaka kwabo. ◆ Abantu barwaye ukuyinga barakunda kugira ivyiyumviro bibi kandi birimwo ukuri guke kuri bo nyene, ku buzima bwabo no kuri kazoza kabo. Ikibazo barimwo kirashobora kugorana cane, ariko ukuyinga kurashobora gutuma ibishobisho bidasiguritse vy’ukwihebura n’ukutagira ikimazi. Ivyo bigenda bigabanuka muri rusangi iyo indwara y’ukuyinga yakize. 24 D EP Igicapo 1 : kuyinga n’akabonge « Amitriptyllinea (ATCb) » « Fluoxétine (ISRSc) » Urugero rw’intango k’uwukuze Mirigarama 25 canke 50 agiye kuryama Mirigarama 10 zifatiwe rimwe ku munsi Gusimbiza kuri mirigarama 20 indwi imwe iheze Urugero rw’intango ku muyabaga Nta kwandika ubwoko bw’uyu muti ku muyaga ata gituma kiboneka Mirigarama 10 rimwe ku munsi Urugero rw’intango ku bageze muza bukuru no ku barwaye Mirigarama 25 igihe co kuryama Mirigarama 10 rimwe ku munsi Ukwongereza urugero kuwukuze Kwongereza hagati ya mirigarama 25 na 50 ku ndwi Ata mitende ibonetse inyuma y’indwi 6, duza kuri mirigarama 40 rimwe ku munsi Urugero rusanzwe ari ngirakamaro kuwukuze Hagati y’imirigarama 100 -150 (urugero ntarengwa : mirigarama 300)d Hagati ya mirigarama 20-40 (urugero ntarenzwa : mirigarama 80) Urugero rusanzwe ngirakamaro ku miyabaga, abasaza n’abarwayi Hagati ya mirigarama 50-75 (urugero ntarengwa mirigarama 100) Ntagutanga umuti ku muyabaga Mirigarama 20 (urugero ntarengwa mirigarama 40) Inkwirikizi mbi cane kandi zishika gake Umutima utera nabi Kuguma ushaka kugendagenda umwanya wose Kuva amaraso bidasanzwe ku bantu bafata « aspirine » canke iyindi miti y’ubuvyimbe bita « anti inflammatoires non steroidiens » Ivyiyumviro vyo kwigirira nabi (cane cane ku miyabaga n’abakuze bakiri bato n’abisununuye) Inkwirikizi mbi zikunze kuboneka igabanuka ry’umurindi w’amaraso umwumira wo mukanwa, ukugumbiza, ingorane mukurekura umwanda muto, ibizunguzungu, ukubona ibidakeye n’ugusinzira Ukumeneka umutwe, ukwiyambagura, ubukazi, indwara z’umushishito n’amara, ihungabana ry’imibonano mpuzabitsina rishobora kuvurwa Muragaba Hagarika ubwo nyene umuti iyo umurwayi agize indwara y’umunezero ndenzarugero Hagarika ubwo nyene umuti iyo umurwayi agize indwara y’umunezero ndenzarugero a Utegekanijwe mu miti y’ubufasha bwihuta mpuzabisata (OMS, 2011) b ATC isigura « antidépresseur tricyclique » c ISRS isigura inhibiteur selectif de la recapture de la sérotonine » d urugero ruto ariko rukora neza ku wukuze : mirigarama 75 (ugusinzira kuraboneka ku ngero ntonto) 2. Iyo ingingo yo kwandika imiti yo kuyinga yafashwe, hitamwo umuti ujanye (>> igicapo Kuyinga n’akabonge 1). » Hitamwo umuti ujanye n’imyaka y’uwakwituye, indwara asanganywe hamwe n’inkwirikizi mbi z’uwo muti (>> igicapo Kuyinga n’akabonge 1). » Ku miyabaga irenza imyaka 12 : ◆ Tegekanya Fluoxétine [ariko kiretse iyindi miti ituma vyiharije inkabuzo sérotonine ikwiragira bikwiye (Inhibiteurs Selectifs de la Recapture de la Serotonine : ISRS) canke iyindi bita (antidépresseurs tricycliques : ATC)] yonyene iyo ibimeneytso bibandanya canke vyunyutse naho aba yaronse ubufasha mu mibano n’inyifato. » Ku bakenyezi bibungenze canke bonsa : ◆ Kwirinda igihe bishoboka umuti wose w’ukuyinga Tegekanya kwandika umuti w’ukuyinga ku rugero ruto ariko rw’ingirakamaro iyo ubufasha bw’imibano n’inyifato butabaye ngirakamaro. Ku bakenyezi bonsa, irinde Fluoxétine. Igihe bishoboka, iture umuhinga. » Ku bageze mu za bukuru : ◆ Irinde igihe bishoboka « amitriptylline ». » Ku bantu barwaye indwara z’umutima : ◆ ntimwandike amitriptylline. » Ku bantu bakuze bafise ivyiyumviro canke integuro yo kwiyahura : ◆ « Fluoxétine » ibwirizwa kwandikwa imbere y’iyindi. Iyo hari ugushaka kwigirira nabi canke kwiyahura (>> SUI) bikabije, andika umuti w’ukuyinga ku rugero ruto (ikiringo c’indwi nk’akarorero). Saba abafasha umurwayi kubika no kugendereza buri gihe imiti mu kurinda ko yonywa myinshi irengeje urugero. Ubufasha bw’imiti : 1. Tegekanya kwandika imiti y’ukuyinga. » Ku mwana adashikana imyaka 12 : Ntimwandike imiti y’ukuyinga. » Ku muyabaga afise hagati y’imyaka 12 na 18 : Ntimutangure kwiyumvira kwandika imiti. Mutange ubutabazi bwerekeye imibano n’inyifato. » Ku muntu akuze : ◆ Iyo uwakwituye afise iyindi ndwara ifatira ku mubiri ishobora gusa n’ukuyinga (>> Ugusuzuma – ikibazo ca 2), banza kuvura iyo ndwara. Tegekanya iyandikwa ry’imiti y’ukuyinga iyo indwara y’ukuyinga idakira mu nyuma yuko bavuye iyo yindi ndwara yo mu mubiri afise. ◆ Iyo mwibaza ko ibimenyetso ari ibisanzwe bijanye n’ukubura gukomeye (>> Ugusuzuma – ikibazo ca 2), ntimwandike imiti y’ukuyinga. ◆ Vugana n’umurwayi mufatire hamwe ingingo yo kwandika imiti yo kuyinga. Sigura ko : Imiti y’ukuyinga idatera ukuguma uyishaka bikagora kuyiheba. Birakenewe cane gufata umuti buri munsi, nkuko vyanditse. Inkwirikizi mbi z’umuti (icapa ukuyinga n’akabonge1) zishobora kuza iminsi ya mbere ariko ko zigenda ziriheza zo nyene. Harakenewe mu bisanzwe indwi nyinshi kugira haboneke akarusho ku mero, ugushaka canke n’inguvu. ◆ Iyo umuntu yatoye mitende, mu bisanzwe, ugufata umuti w’ukuyinga bizobandanya n’imiburiburi kugeza hagati y’amezi 9 na 12. » Umuti ntushobora guhagarikwa bisanzwe kuko umuntu yumvise kamitende (s’umuti w’ububabare k’uwumenetse umutwe). Menyesha umurwayi ikiringo gitegekanijwe c’umuti. 25 D EP 3. Ikurikirana » Suzuma ingaruka ku muti w’ukuyinga. ◆ Indwi nyinshi zirashobora gukenerwa imbere y’ukwumva ingaruka nziza z’umuti w’ukuyinga. Suzuma neza ko umuti wakoze imbere yo kuduza urugero rwawo. ◆ Iyo ibimenyetso vy’indwara y’umunezero ndenzarugero bibonetse (>> Ugusuzuma, ikibazo 2), hagarika ubwo nyene umuti hanyuma murabe ikigabane >> PSY kugira muvure indwara y’umunezero ndenzarugero. ◆ Tegekanya kugabanya buhorobuhoro umuti hagati y’amezi 9 na 12 ibimenyetso bimaze kuzimangana. Gabanya ku rugero rutegekanijwe ku kiringo c’indwi zine n’imiburiburi. » Ringaniza kandi shira mu ngiro ukubonana gutunganijwe kugihe bijanye n’ingingo ngenderwako z’ubufasha (>> Ingingo ngenderwako z’ubuvuzi). ◆ Himiriza ikurikiranwa uko ritegekanijwe precedee par guiemets. ◆ Tegekanya isango rya kabiri mundwi imwe hanyuma amasuzumwa akurikira ufatiye kukugene indwara yagiye ihinduka. Igicapo Kuyinga n’akabonge 2 : ukuvura indwara y’ukuyinga y’ubu ku muntu afise indwara y’imero 2, kirazira kwandika umuti w’ukuyinga wonyene utamuhaye n’umuti w’indwara y’umunezero ndenzarugero, kuko imiti y’ukuyinga irashobora gutera indwara y’umunezero ndenzarugero. Iyo umuntu yagize muri kahise indwara y’umunezero ndenzarugero : » Iture umuhinga. » Iyo umuhinga atabonetse muri uwo mwanya, andika umuti w’ukuyinga hamwe n’uwumunezero ndenzarugero nka « carbamazépine » canke « valproate » (>> icapa DEP 2). ◆ Tangura umuti k’urugero ruto, duze buhorobuhoro indwi zikurikira. Iyo bishoboka, irinde « carbamazépine » na « valproate » k’umukenyezi yibungenze canke abitegekanya kubera ingaruka mbi ku mwana yibungenze. Ingingo yo gutangura umuti w’indwara y’umunezero ndenzarugero k’umukenyezi yibungenze ibwirizwa gufatwa hamaze kuba ukuganira n’uwo mukenyezi. Ubukazi n’incuro z’indwara y’umunezero ndenzarugero n’ukuyinga birafatirwako. ◆ Iture umuhinga kugira yandike umuti w’umwanya munini ku ndwara y’imero zibiri. » Bwira umurwayi n’abamufasha guhagarika ubwo nyene imiti y’ukuyinga ace agaruka kwisuzumisha iyo habonetse ibimenyetso vy’indwara y’umunezero ndenzarugero. Icapa Ukuyinga n’akabonge 2 : Imiti yitwa « thymorégulateurs » ku ndwara y’imero zibiri Carbamazépine Valproate Urugero rw’intango mirigarama 200 Mirigarama 400 Urugero rusanzwe ngirakamaro Hagati ya mirigarama 400-600 Hagati ya Mirigarama 1000-2000 (urugero ntarenzwa mirigarama 2500 ku munsi) Indinganizo y’ugutanga umuti Kuwunywa Kabiri ku munsi Kuwunywa Kabiri ku munsi Ingaruka mbi z’umuti zitaboneka kenshi ariko zihambaye ◆ Kwama uduherehere kumubiri bikabije, (umubiri uravyimba ukamyoka, nk’ubushe butewe n’umuti*) ◆ ukugabanuka kw’umusokoro* ◆ Kwisinzirirako ◆ Gucanganikirwa Ingaruka mbi zikunze kuboneka ◆ Ukwisinziriralo ◆ Ihungabana ry’ugutambuka ◆ Iseseme ◆ Kugeramira ubuzima bw’umwana yibungenzwe ◆ Kwisinzirirako ◆ Kujugumira ◆ Iseseme, ugucibwamwo ◆ Iyongerekana ry’ibiro ◆ Ivungagurika ry’ imishatsi rimara umwanya muto (ugusubira gukura mu bisanzwe bifata ikiringo kiri munsi y’amezi atandatu) ◆ Ihungabana ry’ugukora kw’igitigu

27 ES PT Ihahamuka ESPT Nk’uko twabibonye mu kigabane c’uruhagara rw’umushuhira (STR) rwo mu mutima, birakunda kwibonekeza ko mu bihe vy’ubutabazi, abakuze, imiyabaga n’abana bari mu ruhagarara rwo mu mutima rukomeye, berekana ibimenyetso bitandukanye hamwe n’ihungabana ry’inyifato. Ku bantu benshi, ivyo bimenyetso bimara umwanya muto. Igihe umurwi w’ibimenyetso vyihariye (igarukagaruka, kwirinda, hamwe n’ibigumbagumba bivuye kukwikeka icago buri mwanya) bibandanya mu kiringo kirenga ukwezi inyuma y’igihe gishobora kuba nseserezamutima, umuntu arashobora kuba yarwaye ihahamuka (ESPT). Naho yitwa uko, ESPT siyo yonyene gusa canke indwara ikomeye gusa yibonekeza igihe hibonekeje ibihe bishobora kuba nseserezamutima. Ivyo bihe bishobora no gutera indwara nyinshi zo mu mutwe, z’imitsi nsonzabwenge canke zifatiye ku gufata ibiyayuramutwe zivugwa muri kino gitabu. Ibituma nyezima umuntu yivuza ihahamuka Abantu barwaye ihahamuka birashobora kugorana kubatandukanya n’abandi bafise izindi ndwara kuko mu ntango baba bafise ibimenyetso atari ivy’iyo ndwara gusa nka : » Ihungabana ry’itiro (nk’akarorero kubura itiro) » Gukara, mero igumaho yo kuyinga canke guhagarika umutima » Ibimenyetso bitandukanye bigumaho vy’umubiri bitavuye ku ngorane y’umubiri (nk’akarorero kumeneka umutwe, umutima ugatera cane). Naho biruko, ukuganira kwimbitse kurashobora kwerekana ko bafise ibimenyetso biranga ESPT. 28 ES PT Ugusuzuma Ugusuzuma: Ikibazo ca 1 : Uwakwituye yoba yarahuye n’igihe gishobora kuba nseserezamutima haciye ukwezi kurenga ? 8 Indondoro y’ihahamuka irajanye n’ibishikirizwa n’igisata kijanye no gutanga urutonde rw’indwara (CIM-11) ruriko rurategurwa. Ibishikirizwa n’ico gisata bishira ihahamuka mu kwezi bisigura indwi nkeya habaye ico gihe. Ico gisata nticerekana ibimenyetso bitiharijwe n’ihahamuka nko : kuyamira n’ukwiyambagura. » Baza ko uwakwituye yagize igihe gishobora kuba nseserezamutima. Igihe nseserezamutima n’igihe gishobora kuba giteye ubwoba canke gihambaye, nk’ikubagurwa ryo ku mubiri canke rifatiye kugitsina (harimwo n’ihohoterwa ryo mu ngo), kuba mu bugizi bwa nabi, isamburwa ry’inzu y’umuntu canke amasanganya n’ibikomere bihambaye. Nk’akarorero baza ibibazo bikurikira : ◆ Ni gute woba warahungabanijwe n’ikiza/amatati vyabaye ? Ubuzima bwanyu bwoba bwarageramiwe? Mwoba mwarashikiwe n’ikintu giteye ubwoba canke gitungurura umutima canke kuvy’ukuri cabahungabanije muhira canke mu kibano ? » Igihe uwakwituye yaciye mu gihe gishobora kuba nseserezamutima, baza igihe cabereye. Ugusuzuma : Ikibazo ca 2 : Iyo hibonekeje igihe gishobora kuba nseserezamutima haciye ukwezi kurenga, umuntu yoba arwaye ESPT8 ? » Rondera : ◆ Ibimenyetso vy’igarukagaruka. Ni ukwibuka kwisubiriza kandi umuntu adashaka kw’igihe camusesereje nk’uko womenga kiriko kibera aha n’ubunyene (nk’akarorero bigafata ishusho y’indoto mbi, igarukagaruka* canke ukwibuka vyitamwo* biherekezwa n’ubwoba budasanzwe canke gutunguruka umutima). Kubana, ivyo birashobora gutuma baguma basubira gukina canke bacapa urutavanako igihe cashitse. Abana bakiri bato bashobora kugira indoto ziteye ubwoba zidasiguritse. ◆ Ibimenyetso vyo kwirinda. Ni kwirinda nkana ivyiyumviro, ukwibuka, imigirwa canke ibihe vyibutsa umuntu igihe (nk’akarorero, uwo muntu aririnda kuvuga ibijanye n’icago canke kuja aho cabereye). ◆ Ibimenyetso bijanye n’ibigumbagumba bivuye kukwikeka icago buri mwanya (vyitwa kenshi << ibimenyetso vyo kwama ugavye cane >>). Vyibonekeza nk’uko ari igihe c’umwitwarariko udasazwe no kugaba imbere y’icago canke inyifato irenze urugero yumvise induru canke akandi kantu gakakaje atari avyiteze (nk’akarorero umuntu arakangagurika canke agashavura vyoroshe). ◆ Ingorane zikomeye mu kurangura imirimo ya minsi yose. » Igihe ivyo vyose vyavuzwe aho hejuru bihari mu kiringo cababa ukwezi inyuma y’igihe nseserezamutima, aba ari ESPT. Ugusuzuma : ikibazo ca 3 : hoba hari iyindi ndwara afise kireste iyo aje kwivuza ? » Rondera kandi uvure indwara zose z’umubiri afise zoshobora gusigura ibimenyetso afise. » Rondera kandi vura izindi ndwara zose zo mu mutwe, z’imitsi nsozambwenge n’iziturutse kugufata ibiyayuramutwe zivugwa muri kino gitabu. 29 ES PT 1. Menyesha ibijanye n’ihahamuka ESPT Indinganizo y’ubufasha nshimikiro » Sigura ko : ◆ Abantu benshi bashobora kurengera ihahamuka ata muti uko igihe gihera, mu gihe abandi bakenera umuti. ◆ Abantu barwaye ihahamuka barabangamirwa n’ukwibuka batifuza kw’igihe nseserezamutima. Igihe ivyo bishitse, barashobora kugira ibishobisho nk’ubwoba, canke gutunguruka umutima, bisa n’ibimenyetso bagize mu gihe c’icago nyezina. Barashobora no kugira indoto mbi. ◆ Abahahamutse bama babona ko bashobora kugira icago kandi barashobora kuguma bari mu ruhagarara. Barashobora gukangagurika ningoga (canke bakaraka) canke bagacungera ikintu cose cotera ingorane. ◆ Abahahamutse bagerageza kwirinda ico cose cobibutsa ivyababayeko. Iyo nyifato yo kwirinda irashobora gutera ingorane mu buzima bwabo bwa minsi yose. ◆ (Igihe biruko), abahahamutse barashobora kugira izindi ndwara z’umubiri nizo mu mutwe, nk’ububabare no kuvunagurika umubiri wose, gucika intege, kuruha, gushavura ningoga n’ivyiyumviro bibi cane. » Gira inama uwakwituye yo : ◆ Kubandanya ibikorwa bisanzwe vya minsi yose, uko ashoboye kwose. ◆ Kuganira n’abantu babizigirwa uko yiyumva canke ivyabaye, ariko gusa igihe avyiteguriye. ◆ Gutangura imyimenyerezo ngororamubiri kugira agabanye guhagarika umutina hamwe n’uruhagarara. ◆ Kwirinda kunywa inzoga canke ibiyayuramutwe mu kurengera ibimenyetso vy’ihahamuka. 2. Tanga ubufasha bw’imibano n’inyifato nk’uko bivugwa mu ngingo ngenderwako zo kugabanya uruhagara no gukomeza gushigikirana mu kibano (>> Ingingo ngenderwako z’ubuvuzi) » Hangana n’ibitera uruhagarara mu nyifato n’imibano bihari. ◆ Igihiye umuntu yasinzikajwe n’ihohoterwa rikomeye ry’agateka ka zina muntu, ganira nawe kubijanye n’irungikwa rishoboka mu kigo cizewe gikingira agateka ka zina muntu. » Komeza ugushigikirana mu kibano. » Igisha ubuhinga bwo guhangana n’uruhagarara rwo mu mutima. 3. Igihe hariho abavuzi babinosoye kandi babimenyereye, tegekanya irungikwa ku : » Ubuvuzi bufatiye ku vyiyumviro n’inyifato vy’inyuma y’icago* ; » Ubuvuzi EMDR (Kuvura ibikomere nseserezamutima ukoresheje uguhindukiza amaso uva iburyo uja i bubamfu)*. 4. Ku bantu bakuze, tegekanya kwandika imiti y’indwara yo kuyinga (inhibiteurs sélectifs de la recapture de la sérotonine ou antidépresseurs tricycliques) igihe ubuvuzi bufatiye kuvyiyumviro n’inyifato, ubuvuzi EMDR canke ubuhinga bwo kuvura uruhagara rwo mu mutima bitatanze mitende canke bidakorwa. » Tumbera ku kigabane kiraba ivyo kuyinga n’akabonge kugirango umenye vyinshi kw’iyandikwa ry’imiti y’akabonge no kuyinga (>> DEP). ◆ NTAKWANDIKA umuti wo kuvura ihahamuka ku bana n’imiyabaga. 5. Gukurikirana umurwayi » Tegekanya kandi ushire mu ngiro ukugaruka kwa muganga bitunganijwe kwo gukurikirana hakurikijwe ingingo z’ubuvuzi (>> Ingingo ngenderwako z’ubuvuzi). » Tegekanya isango rya kabiri mundwi zibiri canke zine hanyuma ukubonana na muganga bikurikira bivanye n’ingene indwara ibandanya.

PS Y 31 Indwara yo mu mutwe yeruye PSY Abakuze n’imiyabaga barwaye indwara yo mu mutwe yeruye bashobora kwemera cane canke kwumva ibintu bitari ukuri, arivyo bifatwa muri rusangi n’ikibano nk’uburwayi. Mu bisanzwe, abantu bagendana indwara yo mu mutwe yeruye ntibategera ko barwaye indwara yo mu mutwe. Ntibaba bagishoboye gukora nk’uko bisanzwe mu mirimo itandukanye yo mu buzima. Mu gihe c’ubutabazi, barashobora kugira ingorane zijanye n’uruhagarara rwo mu mutima n’ubwoba, ugutakaza ubufasha mu kibano hamwe n’ihagarikwa ry’ubufasha mu vy’ubuvuzi. Izo mpinduka zishobora guteza indwara yo mu mutwe yeruye y’umushuhira canke bikongereza ibimenyetso vyari bihasanzwe. Mu bihe vy’ubutabazi, abo bantu barabangamirwa bikomeye n’ihohoterwa ritandukanye ry’agateka ka zina muntu : ukutitabwaho, uguhebwa, ugutakaza imiryango, uguhohoterwa hamwe no gutumwa agatoke mukibano, nk’akarorero. Ibituma nyezina umuntu aja kwivuza indwara yo mumutwe yeruye Inyifato itabereye (akarorero : imero idasiguritse canke ukutiyitaho, ikiganiro kitaroranye, ukuyerera, ukujonjogora canke intwengo ataco ivuyeko) Kwemera ibitaroranye Kwumva amajwi canke kubona ibintu bitabariho Umwikeko urengeje urugero Ugushaka guke kwo kuba mu bandi canke kuvugana nabo; kubura ishaka ryo kurangura imirimo hamwe n’ibikorwa vya minsi yose. PS Y 32 Ugusuzuma - ikibazo ca 2: ibituma bivuye kundwara y’umubiri y’umushuhira vyerekana ibimenyetso vy’indwara yo mu mutwe yeruye birashobora kuvurwa ? » Rondera ukwemera kutayegayezwa gutandukanye n’ukwemera kw’abandi* gushobora guterwa n’indwara z’umubiri z’umushuhira nk’igikomere co mu mutwe, ubwandu (akarorero: inyonko, ubwandu bugeze kure*, canke bufatiye kugace gatwara umwanda muto*), umwumira hamwe n’izindi mpinduka zijanye n’ihungabana ry’ingene umubiri uhingura ivyo ukeneye (akarorero: igabanuka ry’isukari mu maraso*, igabanuka ry’umunyu mu maraso*). » Rondera ingaruka mbi z’imiti (nk’ akarorero izatewe n’imiti imwe imwe ivura indwara y’inyonko). » Rondera ingaruka mbi zifatiye mu gufata inzoga canke ibiyayuramutwe hamwe n’ikimenyetso cose kiboneka iyo hahagaritswe ibiyayuramutwe (>> SUB). ◆ Kubaza kubijanye no kunywa inzoga, gufata imiti isinziriza canke ibindi biyayuramutwe. ◆ Kumviriza akamoto k’inzoga. Ugusuzuma ikibazo ca 3: yoba ari indwara y’umunezerondenzarugero ? » Kurondera indwara y’umunezero ndenzarugero. Kurondera ibimenyetso bikurikira : ◆ Igabanuka ry’itiro ◆ Imero y’umunezero mwinshi canke kurakara ◆ Ivyiyumviro binyuragirana, ugusa n’uwusamara vyoroshe ◆ Ukwongerekana kw’ugukora, kwumva ubukomezi bwinshi cane canke ukwihuta mu mvugo ◆ Inyifato iza bukwinabukwi kandi itabereye, ukuguma ukina canke ugura ibintu, ugufata ingingo zikomeye ata nteguro nyayo yabaye ◆ Agaciro umuntu yiha karenze igipimo. » Ikiringo c’umunezero ndenzarugero kirashobora kuba co iyo vyinshi muri ivyo bimenyetso biba bihari mu kiringo kirenga iyinga kandi haraho ivyo bimenyetso bitera ingorane zikomeye mw’irangurwa ry’ibikorwa vya minsi yose, canke umuntu ntashobore gukurikiranwa neza iwe. » Mu gihe abantu barwaye indwara yo mu mutwe yeruye bashobora kugira ivyiyumviro, ivyo bemera canke imvugo bitari vyo, ntibisigura ko ivyo avuga vyose atarivyo canke ko ari ivyiyumviro vyiwe. Kumenya kumviriza neza nirwo rufunguruzo rw’ugusuzuma indwara yo mu mutwe yeruye. Ukwitura umuganga kenshi birashobora gukenerwa kugira hashobore kuba ugusuzumwa gukwiye. Ababaherekeje nibo bashobora gutanga amakuru atomoye. » Kurondera ibimenyetso bikurikira : ◆ ukubona ibintu uko bitari* (umwikeko canke ivyemerwa bitari vyo bigumaho no mu gihe haba hari ivyemezo vy’ukuri) Uburyo bwokoreshwa : gushika kure mu kubaza umuntu ico agomba kuvuga hamwe n’ukumviriza neza. ◆ Kumva canke kubona ibintu bitahari* Mwoba mwumva canke mubona ibintu abandi batabona canke batumva ? ◆ Ivyiyumviro bisobanganye biva ku kintu bija ku kindi ata sano bifitaniye, ikiganiro kigoye gukurikirana. ◆ Ivyiyumviro bidasanzwe, akarorero igihe umuntu yibaza ko abandi bashira ivyiyumviro muri we canke ko bashobora gutwara ivyiyumviro vyiwe canke ko ivyiyumviro vyiwe bishobora kurungikwa mu bandi ◆ Inyifato itabereye nk’ibikorwa bidasanzwe, bitagira insiguro , kandi z’ukwiyambagura , inyifato y’umubiri idasanzwe canke umuntu akamera nk’igiti ntiyinyagaze. ◆ Ibimenyetso biguma bigaruka kandi bihungabanya uko umuntu asanzwe akora, cane cane : Kubura intege n’inguvu vyo kurangura ibikorwa n’imirimo ya minsi yose Kubura umunezero no kwikumira Kutiyitaho Kubura ibishobisho no kutabigaragaza. » Indwara yo mu mutwe yeruye ishobora kubaho mu gihe ibimenyetso vyinshi biboneka. Gusuzuma igihe cose icerekana ko ashobora kwiyahura (>> SUI) ubwo nyene n’inyifato yo kugirira nabi abandi. Ugusuzuma Ugusuzuma - Ikibazo 1 : umuntu yoba arwaye indwara yo mu mutwe yeruye ? PS Y 33 Indinganizo y’ubufasha nshimikiro 1. Mu gihe c’indwara yeruye ata bituma vy’umubiri vy’umushuhira bihari A. Ubufasha bw’imiti : 2. Mu gihe ibimenyetso vy’indwara yo mu mutwe yeruye bivuye kumvo z’umubiri (nk’ukwemera ibitari vyo canke ibimenyetso bivuye kuguhagarika inzoga Mu gihe c’ ibimenyetso bivuye k’umuti bituma umuntu ajugumira canke agabanya kwikomakoma canke ntashobore kuguma hamwe : ∙ Gabanya urugero rw’umuti uvura indwara yo mu mutwe yeruye. ∙ Bishitse ivyo bimenyetso bikabandanya n’ubwo urugero rw’umuti ruba rwagabanijwe, koresha mu kiringo gito imiti yo mu bwoko bwa “anticholinergiques”ivura ivyo bimenyetso (akarorero: umuti witwa “biperidène”, ikiringo kiri hagati y’indwi 4 na 8 >> Igicapo 2). Iyo habaye ugukomantara kw’umubiri kw’umushuhira(cane cane gufatiye kw’izosi, ku rurimi n’imibangabanga) : ∙ Hagarika vy’agategenyo imiti y’indwara yo mu mutwe yeruye, mwandike imiti bita “anticholinergiques” (akarorero biperidène >> Igicapo 2). Iyo miti itabonetse, umuti witwa “diazépam” urashobora gutangwa kugira ufashe ukworoherwa mu mubiri). ◆ Iyo bishoboka, iture umuhinga yabinonosoye kugira uronswe insiguro zijanye n’ikiringo umuti uzofatwa n’uko uzohagarikwa. Muri rusangi, ivurwa ry’indwara yo mu mutwe yeruye ribwirizwa kubandanya n’imiburiburi amezi 12 uhereye kuva ibimenyetso biba vyazimanganye. Gabanya buhoro buhoro umuti ku kiringo c’amezi menshi. kutigera uhagarika imiti bukwinabukwi. 3. Mu kiringo c’umunezero ndenzarugero » Vura ico gituma c’umushuhira. ◆ Ku vyerekeye ivurwa ry’ibimenyetso bivuye kuguhagarika inzoga, raba igicapo 1 c ikigabane cerekeye ugufata ibiyayuramutwe. ◆ Mu gihe hari izindi mvo ziturutse ku mubiri zigaragara atari guhagarika inzoga, andika umuti wo kumira uvura indwara yo mu mutwe yeruye ubereye (nk’akarorero kunywa “halopéridol”, mu ntango ku rugero rw’igice ca mirigarama imwe, wuduze gushika hagati ya mirigarama zibiri n’igice na zitanu ku munsi. Imiti ivura indwara yo mu mutwe yeruye yandikwa gusa mu gihe bisaba ko usubiza k’urugero rwiza ukutaguma hamwe, mu gihe c’ibimenyetso vy’indwara yo mu mutwe yeruye canke igihe c’ubukazi. Hagarika imiti mu maguru masha igihe ibimenyetso vy’indwara bitakigaragara. Koresha gutera inshinge mu nyama mu gihe kumira ibinini biba bidashoboka. » Ikiringo c’umunezero ndenzarugero ni kimwe mubigize indwara y’imero zibiri. Mu gihe indwara y’umunezero ndenzarugero y’umushuhira yamaze kuvurwa, umuntu abwirizwa gusuzumwa no kuvurwa nk’uwufise indwara y’imero zibiri bakoresheje umuti ukosora imero witwa “thymorégulateur” nka “valproate de sodium’ canke “carbamazepine”. kwitura umuhinga yabinonosoye kugira avure canke akurikirane amategeko yo ku ndwara y’imero zibiri yo mu gitabu c’ubutabazi gikwiye “Guide d’interventions mhGAP complet”. » Gutanguza umuti uvura indwara yo mu mutwe yeruye wo kumira. Gukoresha umuti bacisha mu mutsi igihe uwo bacisha mu kanwa wananiranye. Rondera kumenya ko umuntu yaramaze gufata imiti ivura indwara yo mu mutwe yeruye kandi ko hari ico yafashije mu kuvura ibimenyetso vy’indwara. Mu gihe arivyo, mwandikire uwo muti nyene ku rugero yahora afata. Igihe uwo muti utabonetse, tanguza uwundi muti. Uruhara rw’uwamuherekeje canke umuremeshakiyago mu gushingura no gufata umuti ni ntangere, mu gihe hatanguwe umuti kugira habe ukuwubahirizwa bikwiye. ◆ Kwandika umuti umwe uvura indwara yo mu mutwe yeruye (nka “halopéridol” >> igicapo 1). ◆ « Gutangura buhoro buhoro kandi ukabandanya buhoro buhoro ». Gutangurira ku rugezo ruto cane rw’umuti ngirakamaro, hama ugende wongereza buhoro buhoro kugira ushike kuco wipfuza hamwe n’urugezo rugereranye ngirakamaro. ◆ Kugerageza umuti igihe gikwiye ukoresheje mubisanzwe urugezo rukwiye imbere yo kwiyumvira ko umuti udashoboye (n’ukuvuga n’imiburiburi indwi 4 kugera kuri 6) (>> igicapo 1). Kwandika urugero ruto ngirakamaro ku bapfasoni bipfuza gusama imbanyi, abibungenze hamwe n’abonsa. ◆ Mu gihe ukwiyambagura kutoba kwashoboye kuvurwa n’umuti uvura indwara yo mu mutwe yeruye wonyene, tanga umuti ufasha gutekana uri mu bwoko bw’imiti bwitwa ”benzodiazepines” (nk’akarorero ”diazépam”, nturenze mirigarama 5 zo kumira) hamwe no kucuja k’umuhinga yabinonsoye mu maguru masha. ◆ kuvura ingarukambi zivuye ku miti. » Gutanguza umuti wo kunywa w’indwara yo mu mutwe yeruye (>> akaburungu kambere hejuru k’agace kajanye n’ubufasha bw’imiti). » Mu gihe umuntu yiyambagura cane kandi yaronse umuti w’indwara yo mu mutwe yeruye, tegekanya kwongeramwo urugero rw’umuti witwa benzodiazépine (nk’akarorero diazépam, nturenze mirigarama 5 zo kumira) hama uce witura umuhinga yabinonosoye mu maguru masha. PS Y 34 2. Gufasha gusubira kumenyera ikibano » Kuvugana n’abajejwe ikibano kugira bahimirize kwakira no kwihanganira uwahora arwaye. » Kworohereza umuntu mu gusubizwa mu bikorwa vy’imibano n’ivy’ubutunzi mu mibano . » Kwegera abaserukira abandi mu kibano nk’abaremesha kiyago, abajejwe umutekano, abajejwe kwitaho ubuzima mu kibano canke abajejwe gufasha abagendana ubumuga. Gusaba ubufasha kugira bafashe uwakize gusubira mu bikorwa vy’ikibano, vy’inyigisho n’ivy’ivyimyuga yiwe. 3. Gushigikira abafasha abarwayi, hisunzwe ingingo ngenderwako zo kugabanya uruhagarara rwo mu mutima no gukomeza gushigikirana mu kibano (>> ingingo rusangi z’ubuvuzi) C. Ikurikirana umurwayi » Gutegekanya no kugirisha inyigisho z’ikurikirana nkuko bitegekanijwe n’ingingo z’ugufasha (>> ingingo rusangi ngenderwako z’ubuvuzi). » Gutegekanya isango rya kabiri ku kiringo kiri munsi y’indwi hama ugusubira kwitura abaganga ufatiye k’urugero indwara igezeko. » Kubandanya ufata imiti y’indwara yo mu mutwe yeruye n’imiburiburi mu kiringo kitari munsi y’amezi 12 uhereye igihe ibimenyetso vyazimanganiyeko. Mu gihe bishoboka, iture umuhinga yabinonosoye kugira agufashe gufata ingingo yo kubandanya canke guhagarika umuti. B. Ubufasha mu mibano n’inyifato : Mu bihe vyose: 1. Guhitamwo inyigisho z’inyifato Ubutumwa buhambaye bugenewe umurwayi canke uwumufasha (abafasha) : » Indwara yo mu mutwe yeruye irashobora kuvurwa kandi umuntu arashobora gukira. » Umwitwarariko wo mu mutima urashobora kutuma ibimenyetso vy’indwara zo mu mutwe vyunyuka. » kugerageza kubandanya uko bishoboka ibikorwa vyo mukibano, inyigisho n’akazi uko bitunganijwe, nubwo ivyo bishoboka kugorana mu gihe c’icago. » Kwirinda kunywa ibiboreza, urumogi canke imiti itanditswe n’umuganga kubera bishobora kwunyura ibimenyetso vy’indwara. » Abantu barwaye indwara yo mu mutwe yeruye babwirizwa gufata imiti bandikiwe kandi bakagaruka ku gihe kugira bakurikiranwe. » Kumenya ko ibimenyetso vyagarutse canke vyiyongereye. Kugaruka kw’ivuriro kuko bishobora kuba ngombwa ko uhindurirwa umuti. Ubutumwa ku bafasha umurwayi : » Kutagerageza kumvisha umurwayi ko ivyo yemera canke ivyo yumva bitari vyo canke bitabaho. » Gerageza kutagira aho uhengamiye kandi ugerageze kuguma ushigikiye umurwayi nubwo inyifato ziwe zigaragara nk’izidasanzwe canke zibangamira abanda. » Kwirinda guterana amajambo n’umurwayi canke kugaragaza ko utamushigikiye. » Kugerageza kumurekera ubwigenge. Irinde kumusuzugura ariko ugerageze gucungera umutekano wiwe n’uw’abandi. » Indwara yo mu mutwe yeruye ntiterwa n’ibirozi canke impwemu mbi (imiyaga). » Kutagiriza umuntu n’umwe canke abagize umuryango ko aribo bateje ingwara yo mu mutwe yeruye. » Iyo umuntu aheruka kwibaruka, ntimumureke wenyene ngo agumane n’umwana muntumbero yo gucungera umutekano w’uwo mwana. Igicapo 1: Imiti ivura indwara yo mu mutwe yeruye Imiti Halopéridola Chlorpromazine Rispéridone Urugero rw’intango Mirigarama 2,5 ku munsi Mirigarama 50-75 ku munsi Mirigarama 2 ku munsi Urugero rw’umuti ngirakamaro muri rusangi Hagati ya mirigarama 4-10 ku munsi (urugero ntarengwa mirigarama 20) 75–300 mg/jourb Mirigarama 75-300 ku munsi (urugero ntarengwa mirigaranma 1000) 4-6mg/jour Mirigarama 4-6 ku munsi (urugero ntarengwa mirigarama 10) Uburyo umuti ufatwa Kumira/Inshinge Kumira kumira Ingaruka mbi zikomeye Ibimenyetso bituma umuntu ajugumira, adadarara canke ntiyikomakome, +++ + + Ukwisinzirirako(abantu bakuze kubw’umwihariko) + +++ + Ugushaka kuja kumwanda muto bikanka ++ Igabanuka ry’umurindi w’amaraso riturutse mu guhaguruka ningoga wari uryamye canke wicaye + +++ + Ingaruka mbi zikomeye z’imiti zigizwe n’ubushuhe bwinshi, ihindagurika ry’umurindi w’amaraso, ugukomantara kw’umubiri, ugucanganikirwa,… Gakec Gakec Gakec a Iraboneka mubikoresho vy’ubutabazi mpuzabigo( OMS,2011) b Gushika kw’igarama imwe bishobora gukenerwa mubihe bikomeye c Gguhagarika umuti w’indwara yo mu mutwe yeruye mu gihe izo ngaruka mbi ziketswe. Shira umuntu ahakanye buhorobuhoro umuhe n’amazi akwiye. Icapa ca 2 : Imiti ikosora ingaruka mbi z’imiti Imiti Bipéridènea Trihexyphénidyle Urugero rw’intango Hagati ya mirigarama 1-2 ku munsi Mirigarama 1 ku munsi Urugero rw’umuti ngirakamaro muri rusangi Hagati ya mirigarama 3- 6 ku munsi (urugezo ntarengwa ni mirigarama 12) Hagati ya mirigarama 5-15 ku munsi (urugezo ntarengwa ni mirigarama 20) Uburyo umuti ufatwamwo Kumira Kumira ingaruka mbi zikomeye z’umuti Indwara y’ugucanganikirwa,indwara y’ukwibagira (ku bantu bakuze vy’umwihariko), +++ +++ ukwisinzirirako(ku bantu bakuze vy’umwihariko + + Ugushaka kuja kumwanda muto bikanka ++ ++ a Iraboneka mubikoresho vy’ubutabazi mpuzabigo (OMS, 2011) 35 EP I Intandara/ Ibisahuzi EPI Intandara n’indwara (iri mu murwi w’indwara zo mu mutwe, z’udutsi nsozabwenge n’iziterwa n’ugufata ibiyayura mutwe). N’indwara ikunze gukurikiranwa mubihe bidasanzwe vy’abantu bo mubihugu bikenye n’ibiri munzira y’amajambere. Intandara ifata imirwi yose y’abantu n’abana bato barimwo. Intandara ni indwara y’udutsi nsozabwenge ngendanwa irangwa n’ibisahuzi atakibiteye vyisubiriza biva kubikorwa vy’udutsi tw’ubwonko bitagenda neza. Hari ubwoko bw’intandara butandukanye, hama iki kigabane kivuga ubwoko bumenyerewe, intandara zirangwa n’ibisahuzi. Intandara zirangwa n’ibisahuzi bituma haba ukudadarara kw’umubiri bitakuvuyeko, bikurakuranwa n’ukworoha kw’umubiri, bitera kujugumira kw’umubiri canke kudadarara kw’umutumba n’amaguru n’amaboko. Iyo ndwara ijana kenshi n’ugutakaza ubwenge. Umuntu agize ibisahuzi arashobora kugwa canke agakomereka. Kuronka imiti ivura intandara rimwe na rimwe birahagarara mu bihe vy’ubutabazi. Mugabo, iyo iyo miti itagumye iboneka, abarwayi b’intandara barashobora gusubira kugira ibisahuzi, bigatuma amagara yabo ageramirwa. Ibituma nyezina umuntu aza kwivuza indwara y’intandara zirangwa n’ibisahuzi Akahise k’intandara canke k’ibisahuzi birimwo kujugumira. Raba igicapo « Intandara 2 » ku rupapuro 40 kugira mumenye vyinshi cane kw’isuzuma no kuvura umuntu yidudagura canke atakaza ubwenge bivuye ku bisahuzi*. 36 EP I Ugusuzuma » Baza uwakwituye n’uwamuherekeje ko yoba amaze kugaragaza kimwe mu bimenyetso bikurikira : ◆ Ibisahuzi mu kiringo kirenga umunota umwe gushika kuri ibiri ◆ Gutakaza canke ihungabana ry’ubwenge ◆ Kubura inguvu canke kudadarara amaguru n’amaboko mu kiringo kirenga umunota umwe gushika kuri ibiri ◆ Kwihekenya ururimi canke kurujanjagura canke gukomereka ku mubiri ◆ Kwigirako umwanda mukuru canke muto muri ico gihe c’ibisahuzi ◆ Inyuma y’ukujugumira kudasanzwe, umuntu arashobora kuja mu gihe co gucanganyikirwa, gutakaza ubwenge, kuyamira canke inyifato itabereye. Umuntu arashobora kandi kuvuga ko arushe, ko amenetse umutwe canke ko ababara mu mubiri. Ugusuzuma - Ikibazo ca 1 : Uwakwituye arakwiza ibifatirwako ku bijanye n’ibisahuzi ? » Uwakwituye arafise ibifatirwako vyose ku bisahuzi bijanye n’uguta amaboko n’amaguru hamwe n’imiburiburi ibindi muri ivyo bimenyetso vy’urwo rutonde rwo hejuru. » Kwikeka ibisahuzi bidatewe n’intandara canke izindi ndwara zo kwa muganga igihe gusa kimwe canke bibiri mu bifatirwaho vyavuzwe hejuru bibonetse. ◆ Iture umuhinga mu gihe uwakwituye amaze kugira ibisahuzi atari intandara akarenga rimwe. ◆ Vura izindi ndwara zo kwa muganga zishoboka wiketse. ◆ Subira umusuzume inyuma y’ikiringo c’amezi atatu. Ugusuzuma - Ikibazo ca 2 : Mu gihe c’ibisahuzi, hariho igituma c’umushuhira ? » Rondera ibimenyetso vy’ubwandu bw’udutsi nsozabwenge : ◆ Ubushuhe ◆ Kumeneka umutwe ◆ Ubwandu bwo mu bwonko* (kudadarara izosi nk’akarorero) » Rondera ibindi bituma bishoboka vy’ibisahuzi : ◆ Isanganya ryo mu mutwe ◆ Ihungabana ry’ingene umubiri uhingura ivy’ukeneye*(nk’akarorero, kugabanuka kw’isukari*, kw’umunyu*) ◆ Ingaruka mbi zitewe no kunwa inzoga birenze canke kuzihagarika bukwinabukwi canke ibiyayura mutwe (>> Icapa SUB 1 ku rupapuro 49) » Hamwe hoba hari igituma c’umushuhira kibonetse c’ibisahuzi, kivure. ◆ Umuti w’intandara ukinga gusubira kugira ibisahuzi ntukenewe muri ico gihe. » Murungike vyihutirwa ku bitaro mu gihe mwiketse ubwandu bw’udutsi nsozabwenge*, isanganya ryo mu mutwe canke ihungabana ry’ingene umubiri uhingura ivy’ukeneye. ◆ Ikeke ubwandu bw’udutsi nsozabwenge ku mwana (amaze amezi 6 gushika imyaka 6) agaragaje ubushuhe hamwe na kimwe muri ibi bifatirwako ku bisahuzi vy’ubushuhe bidasanzwe : Ibisahuzi bitangurira ku gice kimwe c’umubiri Ibisahuzi bibandanya- bimara iminota irenga 15 Ibisahuzi vyisubiriza- ikiringo kirenze kimwe. ◆ Mu gihe atanakimwe kibonetse muri ivyo 3 bifatirwako bihejeje kuvugwa ku mwana ashushe, n’ukwikeka ibisahuzi bisanzwe bivuye ku bushuhe. Vura ubushuhe kandi urondere n’icabuteye ukurikije intumbero yaho hantu ya PCIME. Guma mwihweza umwana mu kiringo c’amasaha 24 . » Subira kumusuzuma mu kiringo c’amezi atatu. Ugusuzuma – Ikibazo ca 3 : Mu gihe c’ibisahuzi ata mpamvu y’umushuhira ibonetse, zoba ari intandara ? » Indwara y’intandara yikekwa mu gihe umuntu agize ibisahuzi bibiri canke birenga ataco bivuyeko ku minsi ibiri itandukanye mu kiringo c’amezi cumi n’abiri aheze. » Mu gihe habaye igisahuzi kimwe gusa mu mezi cumi n’abiri aheze atacabiteye cihuta, umuti w’intandara ntukenewe. Subira kumusuzuma inyuma y’amezi atatu. 37 EP I Indinganizo z’ubufasha nshimikiro 1. Menyesha uwakwituye n’abamuherekeje kubijanye n’intandara » Sigura : ◆ Ico ari co indwara y’intandara n’ibizitera : Indwara y’intandara n’indwara ngendanwa, ariko hafashwe umuti, abantu batatu kuri bane barashobora kudasubira kugaragaza ibisahuzi. Indwara y’intandara yerekanwa n’ibisahuzi vyisubiriza. Ibisahuzi biva kw’ikora nabi ry’udutsi nsozabwenge tw’ubwonko Indwara y’intandara ntiterwa n’uburozi canke imizimu. Indwara y’intandara ntiyandukira. Intandara ntiyandukira biciye mu mate. ◆ Inkurikizi z’intandara ku buzima bwa minsi yose : Abarwayi b’intandara bashobora kubaho ubuzima busanzwe : ∙ Barashobora kurongora no kurongorwa no kuronka abana bakomeye ∙ Barashobora gukora neza ubuzi butandukanye ∙ Abana barwaye intandara barashobora kuja kwiga Abarwayi b’intandara bategerezwa kwirinda : ∙ Ibikorwa bisaba gukorerwa hafi y’amamashine canke umuriro ∙ Gutekera ahantu hari urubeya ∙ Kwoga uri wenyene mu mazi menshi ∙ Kunwa inzoga canke ibiyayuramutwe ∙ Kuraba umuco ubengagirana ∙ Guhindagura akamenyero k’itiro (kuryama amasaha make kuruta uko vyari bisanzwe nk’akarorero). ◆ Ico wokora muhira mu gihe iyo ndwara yomufata (ku bafasha) : Hamwe iyo ndwara yofata uwo murwayi ahagaze canke yicaye, kingire kurwa mu kumufasha kwicara bukebuke canke kuryama. Menya neza ko umurwayi ahema neza. Tezura impuzu zifata mw’izosi. Ryamikira umuntu ku rubavu bimukingira (Raba amasanamu A-D aha munsi). Amasanamu A-D : Kuryamira urubavu bimukingira A. Pfukama iruhande y’umurwayi. Shira ukuboko kuri hafi cane kunfuruka ngororotsi y’umubiri, ukundi kuboko ukujane amaja ku mutwe (Raba isanamu A). B. Shira ukundi kuboko kuruhande rw’umutwe w’umurwayi, ku buryo bwuko inyuma y’ikiganza hakora kw’itama (Raba isanamu B). C. Pfunya ivi riri kure cane y’imfuruka ngororotsi. Shira umurwayi ku rubavu bukebuke mu gukwega ivi ripfunyije (Raba isanamu C). D. Ukuboko kuri hejuru gusegura umutwe, mu gihe ukuboko kuri munsi gufasha kubuzako umurwayi atembagara (Raba isanamu D). Fasha umurwayi guhema neza usubiza umutwe inyuma mu kuduza agasakanwa, kandi urabe neza ko atakintu na kimwe kizibiye inzira zo guhema. Ubwo buryo butuma ururimi rutazibira inzira zo guhema, butuma umurwayi ahema neza kandi bikabuza ko abura impwemu bivuye k’uruterute n’ibidahwe. Kirazira gufatira umurwayi hasi. Ntanakimwe ushira mu kanwa. Igiza inyuma ibintu vyose bikomeye canke bisongoye kure y’umurwayi kugira umurinde gukomereka. Gumana n’umurwayi gushika y’aho igisahuzi kimuvako kandi agasubira gutora ubwenge. A C B D » Bwira umurwayi n’abamuherekeje ko botunga agakaye ko kwandikamwo incuro ibisahuzi vyagiye biramufata Igicapo Intandara/ibisahuzi 1. 38 EP I Icapa EPI 1 : Imiti y’intandara Phénobarbitala Carbamazépine Phénytoïne Valproate Ingezo yo gutangura k’umwana 2-3 mg/kg k’umunsi 5 mg/kg/ k’umunsi 3-4 mg/kg/ k’umunsi 15-20 mg/kg/ k’umunsi Ingezo muri rusangi ivura k’umwana 2-6 mg/kg k’umunsi 10-30 mg/kg k’umunsi 3-8 mg/kg k’umunsi (urugezo ntarengwa˸ 300 mg k’umunsi) 15-30 mg/kg k’umunsi Ingezo yo gutangura k’uwukuze Mirigarama 60 ku munsi Hagati ya mirigarama 200-400 ku munsi Hagati ya mirigarama 150-200 ku munsi Mirigarama 400 ku munsi Ingezo muri rusangi zivura k’uwukuze 60-180 mg k’umunsi 400-1400 mg k’umunsi 200-400 mg k’umunsi 400-2000 mg k’umunsi Igicapo c’ingero Rimwe ku munsi ugiye kuryama Kabiri ku munsi Ku mwana, n’ugufata kabiri ku munsi ; ushobora gufatwa rimwe ku munsi k’uwukuze Muri rusangi 2-3 ku munsi Ingaruka mbi z’imiti ziboneka gake ariko zihambaye ◆ Ukwunuka gukomeye kw’urukoba rw’umubiri (syndrome de StevensJohnson*) ◆ Igabanuka ry’umusokoro w’igufa* ◆ Igabanuka ry’ubushobozi bwo gukora bw’igitigu ◆ Ukwunuka gukomeye kw’urukoba rw’umubiri (syndrome de StevensJohnson*, kwunuka kw’umubiri*) ◆ Igabanuka ry’ubushobozi bwo gukora bw’igitigu ◆ Gukama amaraso n’ubundi busembwa bwo mu maraso ◆ Gufurutirwa harimwo n’ukwunuka gukomeye kw’urukoba rw’umubiri (syndrome de StevensJohnson*) ◆ Ubwandu bw’igitigu butewe n’umugera ◆ Kwisinzirirako ◆ Gucanganyikirwa Ingaruka mbi z’imiti zikunze kuboneka ◆ Kwisinzirirako ◆ Umwete urenze ku mwana ◆ Kwisinzirirako ◆ Ingorane zo gutambuka ◆ Iseseme ◆ Iseseme, kudahwa, kugumbiza ◆ Kujugumira ◆ Kwisinzirirako ◆ Ingorane zo gutambuka n’ingorane zo kuvuga n’ugukurikiranya amajambo ◆ Inyifato ifatiye ku gice kimwe c’umubiri iguma igaruka ◆ Gucanganyikirwa ◆ Itiro ry’inshi rifatanije n’ukubura inguvu ◆ Kwisinzirirako ◆ Kujugumira ◆ Iseseme, gucibwamwo ◆ Kuduza ibiro ◆ Kuvungagurika kw’imishatsi (isubira gukura mu mezi 6) ◆ Ihungabana ry’ikora ry’igitigu Ivyo kwitondera ◆ Irinde « phenobarbital ku bana bafise ubukehabwenge n’ingorane z’inyifato ◆ Irinde «valproate » k’umukenyezi yibungenze a Biri mu bikenewe mpuzamashirahamwe vyihuta vy’amagara y’abantu (OMS, 2011) 2. Tangura canke usubire gufata umuti w’intandara » Suzuma namba umurwayi yaramaze gufata umuti w’intandara woba waramugiriye akamaro. Mu gihe avyemeye, mwandikire kur’urwo rugero nyene. » Igihe uwo muti utabonetse, tangura uwundi. » Hitamwo umuti umwe gusa w’intandara (Raba icapa EPI 1). ◆ Iyumvire ku ngaruka mbi z’umuti zishoboka, kurwara bivuye k’umuti warugenewe kuvura iyindi ndwara* canke gukorana kw’imiti* bishoboka. Mu gihe bihari, isunge ibifatirwako ku rwego rw’igihugu canke ku rwego rw’ishirahamwe mpuzamakungu ryitaho amagara y’abantu. ◆ Tanguza urugezo rutoya hanyuma ugende uduza buke buke urugezo gushika aho ibisahuzi bitakimufata. » Sigurira umurwayi n’abamuherekeje : ◆ Igicapo c’ingero (>> icapa EPI 1). ◆ Ingaruka z’umuti (>> icapa EPI 1). Nyinshi mur’izo n’izisanzwe kandi zigenda zihera buke buke. Mu gihe habonetse ingaruka mbi z’umuti zikomeye, umurwayi ategerezwa guhagarika umuti hama akisuzumisha ku muganga. ◆ Akamaro k’ukwubahiriza umuti. Ukwibagira gufata umuti canke kuwuhagarika bukwinabukwi bishobora gutuma ibisahuzi bigaruka. Imiti itegerezwa gufatwa ku masaha amwe buri munsi. ◆ Ikiringo gikenewe kugira umuti utangure gukora. Muri rusangi hategerezwa guhera indwi nkeya kugira haboneke mitende. ◆ Ikiringo co gufata umuti. Kuva ibimenyetso bimaze guhera bandanya umuti gushika ku myaka ibiri n’imiburiburi. ◆ Akamaro ko gukurikiranwa uko bitegekanijwe. 39 EP I Icapa Intandara/Ibisahuzi 1 : Uburyo bwihariye bwo kuvura umukenyezi arwaye intandara » Igihe umukenyezi ari mu myaka yo kurondoka : ◆ Andika miligarama 5 ku munsi za « acide folique » kugira ukingire umwana ari mu mbanyi ubusembwa bushoboka imbere yo kuvuka. » Hamwe yoba yibungenze : ◆ Iture umuhinga kugira amuhe ubufasha. ◆ Tegekanya gukurikirana imbanyi kenshi gashoboka no kwibarukira ku bitaro. ◆ Mu gihe co kuvuka,uruyoya ruraronswa miligarama 1 ya vitamine K mu rushinge rwo munyama. » Ingingo yo gutangura umuti w’intandara ku mukenyezi yibungenze bitegerezwa kubanza kwigirwa hamwe nawe. Ubukomezi n’incuro z’ibimenyetso hamwe n’ingaruka zishobora gushikira umwana ari mu mbanyi (bivuye ku bisahuzi canke ku muti) vyotegerejwe gufatirwako. Mu gihe ingingo yo gutangura umuti ifashwe, phénoharbital na carbamazepine niyo ishirwa imbere. Valproate hamwe no gukoresha imiti myinshi* n’ukuzovyirinda. » Carbamazepine irashobora gukoreshwa ku mukenyezi yonsa. » Gira ikurikirana ritunganijwe : ◆ Mu kiringo c’amezi atatu yambere canke gushika aho ibimenyetso bihereye, tegekanya amasango yo gukurikiranwa n’imiburiburi rimwe mu kwezi. ◆ Mu gihe ibimenyetso vyaheze, bonana n’umurwayi buri mezi atatu. ◆ Raba ingingo ngenderwako z’ubufasha (>> ingingo ngenderwako z’ubuvuzi) kugira umenye vyinshi ku vyerekeye gukurikiranwa. » Kuri buri sango ryo gukurikiranwa : ◆ Cungera uko ibisahuzi bigenda bihera : Koresha agakaye k’incuro ibisahuzi bimufata kugira urabe uko bigenda bihera. ◆ Bandanya canke uhindure urugezo rw’umuti w’intandara wisunze uko ibimenyetso bimeze. Hamwe ibimenyetso bitoba birahera k’urugezo rw’umuti rwo hejuru canke hamwe ingaruka z’umuti zoba mbi cane, wuhindure. Duza buke buke gushika aho ibimenyetso bihera. Mu gihe ibimenyetso biboneka gake cane kandi gusubira kuduza urugero rw’umuti vyoshobora gutera ingaruka mbi cane, tegekanya kugumiza k’urugezo rw’ubu. Iture umuhinga hamwe imiti ibiri yoba yarakoreshejwe umwe inyuma y’uwundi ntihagire n’umwe ushobora guhagarika neza ibisahuzi. Irinde gutanga umuti urenze umwe w’intandara icarimwe. ◆ Tegekanya guhagarika umuti w’intandara mu gihe atakimenyetso na kimwe cigeze kiboneka mu kiringo c’imyaka ibiri. Mu gihe co guhagaruka umuti, urugezo rugenda ruragabanuka buke buke mu kiringo c’amezi menshi kugira wirinde igaruka ry’ibimenyetso bivuye kwihagarikwa bukwinabukwi ry’imiti. ◆ Guha uruhara abaherekeje umurwayi mu gucungera uko ibimenyetso biza birahera. ◆ Tohoza uko umuntu abayeho kandi tanga inyigisho/ubufasha bwiyongerako ku murwayi n’abamuherekeje (>> ikigabane ca 1 c’indinganizo y’ubufasha nshimikiro bihejeje kuvugwa). 3. Ikurikirana Igicapo intandara/ibisahuzi 1. Akarorero k’agakaye kerekana uko ibisahuzi biza biramufata Ibihe vy’ibisahuzi Indondoro y’ibisahuzi (harimwo n’ibice vy’umubiri vyafashwe n’igihe ibisahuzi vyamaze) Imiti yafashwe Itariki Isaha Ejo Uno munsi 40 EP I Icapa Intandara/ibisahuzi 2 : Ugusuzuma no kuvura umuntu afashwe n ibisahuzi canke yataye ubwenge kubera indwara Ugusuzuma no kuvura ibisahuzi vy’umushuhira bitegerezwa kubera rimwe. » Ugusuzuma ibisahuzi ◆ Guma utekanye. Vyinshi muri ivyo bisahuzi birihagarika mu kiringo c’iminota mikeyi. ◆ Suzuma ibice vy’ihemero, guhema, harimwo n’itembera ry’amaraso, incuro umuntu ahema kumunota n’ubushuhe. ◆ Suzuma ibimenyetso vy’isanganya ryo mu mutwe, ry’uruti rw’umugongo (imbonero zagutse zishobora kuba nk’akarorero ikimenyetso c’isanganya ryo mu mutwe rikomeye). ◆ Suzuma kudadarara kw’izosi canke kugira ubushuhe (ibimenyetso vy’ubwandu bw’ubwonko). » Baza ibibazo bikurikira uwamuherekeje : ◆ Ni ryari igisahuzi catanguriye ? ◆ Muri kahise hari ibisahuzi yoba yarigeze kugira ? ◆ Hari isanganya ryo mu mutwe canke kw’izosi yoba yaragize muri kahise ? ◆ Hari izindi ngorane zo kwa muganga yoba afise ? ◆ Umurwayi yoba yaranyoye imiti, ishano, inzoga canke ibiyayura mutwe ? ◆ Mu gihe yoba ari umukenyezi ; yoba ari mu gice ca kabiri c’imbanyi canke nta ndwi irahera yibarutse ? » Murungike vyihuta ku bitaro : ◆ Mu gihe yoba afise ibikomere bikomeye, Igabanuka ry’itembera ry’amaraso rivuye ku kuvirirana* canke ingorane zo guhema ◆ Hamwe umurwayi yoba yagize isanganya ryo mu mutwe canke ryo kw’izosi : Ntunyiganze izosi ryiwe. Koresha uburyo bwo kumuhindukiza wese aramvuye kugira ushobore kumurungika ku bitaro. ◆ Hamwe umurwayi yoba ari umukenyezi ari mugice ca kabiri c’imbanyi canke ata ndwi irahera yibarutse ◆ Hamwe wokwikeka ubwandu bwo mu bwonko ◆ Hamwe hoba haheze iminota itanu ibisahuzi bitanguye. » Kuvura ibisahuzi ◆ Ryamikira umurwayi ku rubavu rumukingira (raba indinganizo zo kuvuva nshimikiro hamwe n’amasanaumu A-D aho hejuru. ◆ Hamwe ico gisahuzi kitihejeje mu kiringo c’umunota gushika kuminota ibiri, rondera umutsi vyihuta uce umuha iserumu iduza isukari mu mubiri harimwo n’umuti « benzodiazépine » bukebuke (amama 30 ku munota). Mu gihe umutsi wogorana gutora, tanga umuti « benzodiazépine »ucishije mu kibuno. Muragabe : imiti « benzodiazépines »irashobora kugabanya ingene umuntu ahema. Iyo bishoboka, tanga impwemu « oxygène » muheze musuzume kenshi uko uwo muntu ahema. Urugezo rw’isukari ku mwana : hagati ya mirigarama 2 -5 ku kilo z’isukari ku bice cumi kw’ijana. Urugezo rw’umuti « benzodiazépines » ku mwana : ∙ « diazépam » mu kibuno 0,2-0,5 miligarama ku kilo canke ∙ « diazépam » ucishije mu mutsi 0,1-0,3 miligarama ku kilo canke ∙ « lorazépam » mu mutsi 0,1 miligarama ku kilo Urugezo rw’isukari k’uwukuze : hagati ya mililitiro 25-50 z’isukari ku bice 50 kw’ijana Urugezo rwa « benzodiazépines » ku wukuze : ∙ « diazépam » mu kibuno miligarama 10-20 canke ∙ « diazépam » ucishije mu mutsi miligarama 10- 20 canke ∙ « lorazépam » mu mutsi miligarama 4 Ntutange imiti « benzodiazépines » ucishije munyama. ◆ Tanga urugezo rwa kabiri « benzodiazépines » hamwe ibisahuzi bibandanije iminota 5-10 inyuma y’ urugezo rwa mbere. ◆ Muhe urugezo rungana n’urwambere. ◆ Ntutange ingezo zirenga 2 za « benzodiazépines ». Umurwayi niyaba akeneye ingezo zirenga 2, ca umurungika ku bitaro. ◆ Kwikeka indwara y’intandara yisubiriza atakugarukana ubwenge hagati y’igisahuzi n’ikindi kenshi ku munsi igihe : Ibisahuzi ari vyinshi cane ku buryo umurwayi adasubira gutora ubwenge hagati y’ikiringo n’ikindi, canke Ibisahuzi bidahagarara ku ngezo zibiri zambere za « benzodiazépines », canke Ibisahuzi bimara iminota 5 irenga. » Kurungika vyihuta ku bitaro : ◆ Hamwe wokwikeka indwara y’intandara yisubiriza kenshi ku munsi (raba aho hejuru) ◆ Hamwe umurwayi atogira mitende ku ngezo 2 za mbere za « benzodiazépines » ◆ Hamwe umurwayi yogira ibibazo vyo guhema inyuma yo kuronka « benzodiazépines ». 41 D I Ubukehabwenge DI Ubukehabwenge9 burangwa n’intambamyi zidahera mu mice myinshi y’ugukura kwiza kw’ ubwonko (uko azirikana ibintu*, imvugo, ugukora kw’imitsi, n’imigenderanire n’abantu). Izo ntambamyi ziba zihari kuva mu mavuko canke zigatangura mu bwana. Ubukehabwenge burabangamira ukwiga, ibikorwa vya minsi yose hamwe no kumenyera ahantu hashasha. Abantu bafise ubukehabwenge baba bakeneye ukwitabwaho gukomeye. Barahura kenshi n’ibibazo mu gushikira ubuvuzi mbere n’indero. Mu bibanza birimwo ingorane zikomeye cane, barabangamirwa cane mu guturubikwa, kutitabwaho kandi bakisanga mu bihe bibabangamira. Bashobora, nk’akarorero gutemberera ahantu hatari umutekano batanabizi. Barashobora kandi no kubonwa nk’umutwaro mu muryango wabo no mu kibano, bakanahebwa iyo ari mu bihe vyo kwimurwa. Bategerezwa rero kwitabwaho cane mu bihe vy’ubutabazi bwihuta. Kino kigabane kivuga ku bukehabwenge bubayabaye, bukomeye hamwe n’uburenze urugero ku mwana, umuyabaga hamwe n’uwukuze. Ibituma nyezina umuntu yitura abaganga » Ku mwana atarakwiza imyaka 2 : kubura akayabagu, kuzingama, kugoyagoya, guteba mu gukura ugereranije n’imice isanzwe yo gukura ku mwana (kumwenyura, kwicara, guhagarara). » Ku mwana arenza inyaka 2 : guteba mu gukura ugereranije n’imice isanzwe yo gukura ku mwana (gutambuka, kutiyononako, kuvuga, gusoma no kwandika). » Ku wukuze : ubushobozi buke bwo kubaho mu bwigenge hamwe no kwiyitaho we nyene na/canke kwitaho abana. » Ku myaka yose : ihungabana mu kurangura ibikorwa vya minsi yose bifatwa nk’ibisanzwe ku bandi bangana nkawe, ingorane mu gutahura ivyo asabwa gukora, ingorane mu gukurikiza ibisabwa mu buzima bwa minsi yose. 9 Mu mugambi wa CIM-11, izina ryahiswemwo kuri iyo ngwara ni ihungabana mu gukura kw’ubwenge. 42 D I Ugusuzuma - ikibazo ca 1 : Mbega uwakwituye arafise ubukehabwenge ? Ugusuzuma » Suzuma ubushobozi n’irangurwa ry’bikorwa vy’uwakwituye : ◆ Ku mwana atarakwiza imyaka 2 be no ku bana bakiri bato, suzuma ko bakwije intambwe zose zisanzwe zo gukura mu bisata bitandukanye vyo gukura (>> Igicapo DI I c’ibimenyetso vyo gukurikiranira hagufi). ◆ Uturorero tw’ibibazo vyo kubaza abazanye abana : Umwana wanyu yitwara nk’abandi bana bangana ? Umwana wanyu ashoboye gukora iki atawumufashije (kwicara, gutambuka, kwigaburira, kwiyambika canke kwijana mu bwiherero) ? Umwana wanyu muganira gute ? Yoba amwenyura ? Yoba yitaba umuhamagaye mw’izina ? Umwana abaganiriza gute ? Mbega umwana arashoboye gusaba ico akeneye ? Umwana wanyu akina gute ? Mbega arashoboye gukina n’abandi bana banganya imyaka ? ◆ Ku bana bakuze be n’imiyabaga, baza niba baja kw‘ishure n’ingene bitwara mu bikorwa vyo kw’ishure (ukwiga, gusoma no kwandika) hamwe n’udukorwa two muhira twa minsi yose : Uraja kw’ishure ? Bigenda gute kw’ishure ? birakunda ko uheraheza ibikorwa vyawe ? Woba uhura kenshi na kenshi n’ingorane kubera bidakunda ko utahura canke ukurikiza ibisabwa ? ◆ Ku bakuze, baza nimba bakora, mu gihe bakora batunganya gute ibikorwa vyabo hamwe n’ibindi bikorwa vya minsi yose ? Murakora ? mukora iki ? Hari ingorane muhura kenshi muri mu bikorwa kubera mutashoboye gutahura canke gukurikiza ibisabwa ? ◆ Ku bana bisumbuye, imiyabaga, n’abakuze, baza ubufasha baronswa mu bikorwa vyabo vya minsi yose (nk’akarorero muhira, kw’ishure, ku kazi). » Mu gihe hari uguteba mu gukura ugereranije n’ikiringo kimenyerewe co gukura, rondera indwara zivurwa kandi zigakira zishobora kuba zisa n’ubukehabwenge. ◆ Rondera ubumuga bw’ukubona : Ku bana barenza amezi atandatu, baza uwamuzanye bino bibazo, uguma wihweza umwana : ∙ Umwana yoba akurikiza ijisho ikintu kigendagenda ? ∙ Umwana yoba amenya mu maso h’abantu amenyereye ? ∙ Umwana arashobora kugumya ikintu mu minwe ? Igihe musanze inyishu imwe kuri ivyo bibazo ari « Oya », menyesha uwamuzanye ko umwana ashobora kuba afise ingorane zo kubona hama mwiture umuhinga mu gihe bishoboka. ◆ Rondera ubumuga bw’ukwumva : Ku mwana arenza amezi atandatu, baza uwamuzanye ibibazo bikurikira, uguma wihweza umwana : ∙ Umwana arahindukira kugira arabe uwuriko aravugira inyuma yiwe ? ∙ Umwana yoba aragira ikimenyetso co kwumva urwamo rukomeye ? ∙ Umwana arahoha? (tata, dada, baba) ? Mu gihe inyishu ibaye “Oya” kuri kimwe muri ivyo bibazo, menyesha uwamuzanye ko umwana ashobora kuba afise ingorane zo kwumva, mu gihe bishoboka aheze yiture umuhinga. ◆ Rondera ingorane zitewe n’ibimukikije : Indwara yo kuyinga n’akabonge ya nyina canke y’uwukunda kumwitaho (>> DEP). Kubura ibimukabura (gukaburwa ni ngombwa mu gukura kw’ubwonko bw’abana bato). ∙ Ni nde akunda kumukabura no kumukinisha ? ∙ Mukina gute n’umwana ? Incuro zingana gute ? ∙ Muganira gute n’umwana ? Incuro zingana gute ? ◆ Rondera indwara zo gufungura nabi hamwe n’iziva ku gukehanirwa mu vyerekeye gufungura canke inkaburamubiri, cane cane urugero ruke rw’icunyunyu iyode (iode*) n’ingorane z’ugukora bidakwiye kw’agace tiroyide* (thyroide). ◆ Rondera indwara y’intandara (>> intandara/ibisahuzi) ishobora gusa canke ikazira rimwe n’ubukehabwege. » Kwitaho ingorane zishobora kuvurwa hamwe no gusubira gusuzuma ko uwo muntu afise ubukehabwenge. ◆ Ku bafise ubumuga bw’ukwumva n’ukubona buhambaye, tanga canke usabe ubufasha bukenewe (amarori, akuma gafasha kwumva). ◆ Vura ingorane z’akabonge z’uwazanye umwana mu gihe zihari. ◆ Igisha umufasha uko yoshiraho ibihe bikabura abana. Raba igitabo “Counsel the Family for Care for Development: Counselling Cards (UNICEF et OMS, 2012). ◆ Bibaye ngombwa, rungika uwo muntu aho yofashwa ku bijanye no gukura kw’abana bato (Indinganizo zo gukura kw’abana DPE). » Ubukehabwenge buba buhari: a) mu gihe hari uguteba cane mu gukura ugereranije n’urugero rumenyerewe hamwe no kugira ingorane mu bikorwa vya minsi yose, b) igihe indwara zivurwa zigakira zarondewe bakazibura canke zavuwe. Ugusuzuma – Ikibazo ca 2 : Hari ingorane mu nyifato zifatanye n’ubukehabwenge ? » Ntiyumviriza abamufasha. » Agira ishavu ryiyadukiza. Agaragaza inyifato yo kugirira nabi abandi canke akigirira nabi we nyene iyo adashigikiwe mu vyiyumviro vyiwe. » Arya ibitaribwa. » Agira inyifato mpuzabitsina itabereye canke izindi nyifato zitari nziza. 43 D I Indinganizo y’ubufasha nshimikiro » Sigurira ubukehabwenge umuntu n’abamufasha. Abantu bafise ubukehabwenge ntibategerezwa kubakarira kubera ingwara yabo. Abamufasha bategerezwa kugira ivyo bamwitezeko bisiguritse bijanye n’urugero rw’ubukehabwenge bwiwe kandi bakagaragaza kumwitaho no kumushigikira. » Kwigisha abavyeyi kwimenyereza kwitwararika abana. Intumbero ni iyo guteza imbere imigenderanire hagati y’abavyeyi/abafasha hamwe n’uwo mwana. Igisha abafasha ubuhinga bufasha mu kugabanya ingorane z’uko abantu bitwara. ◆ Abafasha bategerezwa gutahura akamaro ko kwigisha uwo muntu kwiyitaho we nyene hamwe n’isuku (kuja mu kazu ka surwumwe canke kwiyugumura we nyene nk’akarorero). ◆ Abafasha bategerezwa kuba bazi neza uwo muntu. Abafasha bategerezwa kumenya ibimuhagarika umutima hamwe n’ibimuryohera; kumenya inyanduruko y’ingorane mu nyifato n’ukuntu bovyirinda; kumenya ivyo ashoboye, intege nke ziwe n’uburyo bwiza bwo kumwigisha kugira aronke ubumenyi. ◆ Abafasha bategerezwa kumenya ko udukorwa tw’uwo muntu, nko gufungura, gukina, kwiga, gukora no kuryama bikorwa vyubahiriza urugero rutegekanijwe. 1. Tunganya inyigisho z’inyifato ◆ Abafasha bategerezwa kumutera intege iyo yagize inyifato nziza kandi bakareka kumushimira iyo yagize inyifato mbi. Gutanga indero ibereye : Kumubwiriza mu buryo bwumvikana, busanzwe kandi muri make ku vyerekeye ivyo ategerezwa gukora ntimumubwire ivyo atemerewe gukora. Hindura ibikorwa bikomakomeye mu dukorwa dutoduto tw’urukurikirane kugira ngo uwo muntu ashobore kwimenyereza kandi agashimirwa inyuma y’urugezo rwose ahejeje muri utwo dukorwa dutoduto (nk’akarorero kwimenyereza kwambara ipantaro imbere yuko afunga ibifungo). Mu gihe uwo muntu akoze ikintu ciza, mushimire. Samaza uwo muntu ku vyerekeye ivyo atarekuriwe gukora. Iryo samazwa, ntiryama minsi yose rinezereza canke ngo ribonwe nk’agashimwe kuri uyo muntu. NTIHAKORESHWE iterabwoba canke ibihano bibabaza umubiri iyo inyifato idahimbaye. » Menyesha abafasha ko uwo muntu ari umunyantege nke ku vyerekeye ikubagurwa rifatiye ku mubiri no ku gitsina muri rusangi, kandi ko kubw’ivyo akeneye kwitabwaho no gukingirwa vyo ku rwego rushimishije. » Kwigisha abafasha ku bijanye no kwirinda kumushira mu bigo vy’amarerero. » Suzuma ko hariho ugukingirwa gufatiye ku kibano (nk’imirwi yigenga, amashirahamwe yaho hantu ategamiye reta, ibisata vy’intwaro canke amashirahamwe mpuzamakungu) hama usabe ubufasha bwihariye bw’uwo muntu. 2. Guharanira ugukingirirwa gufatiye mu kibano 3. Himiriza guhabwa uruhara mu bikorwa vyo mu kibano » Mu gihe ari umwana, gerageza mumureke yige ikiringo kinini gishoboka. ◆ Gumana imigenderanire n’ishure umwana yigako kugira murabire hamwe uko mwotunganya ibimukikije kwishure. Impanuro zisanzwe zirahari mu gitabo « Inclusive Education of Children AT Risk de l’INEE » (ou Réseau inter-agences pour l’education en situations d’ugence) bisigura (urunani mpuzabisata mu kwigisha mu bihe bidasanzwe). » Himiriza kuja mu dukorwa tumuryohera two mu kibano. » Suzuma ko hariho imigambi yo kwimenyereza mu kibano (RBC*) kandi muharanire ko uwufise ubukehabwenge nawe aja muri iyo migambi. 4. Shigikira abafasha ukurikije ingingo ngenderwako zo kugabanya uruhagarara rwo mu mutima hamwe no gukomeza gushigikirana mu kibano (>> Ingingo ngenderwako z’ubuvuzi) 5. Bishoboka, iture umuhinga kugira asuzume yongere avure neza izindi indwara zijanye no gukura » Ubumuga bw’umubiri budakira canke ubumuga bw’ubwonko*. » Ubusembwa buvukanwa, indwara canke ubumuga bw’akaronda (nk’akarorero indwara y’akaronda iterwa n’ukuboneka kw’agace k’akaremangingo 21 « trisomie 21»*) 6. Ikurikirana » Tegekanya wongere ushire mu ngiro kubonana ku rugero rutunganijwe mukurikije ingingo z’ubuvuzi (>> Ingingo ngenderwako z’ubuvuzi). 44 D I Icapa DI 1: ibiringo bitandukanye vyo gukura: ibimenyetso vyo gukurikiranira hafi Ku kwezi kumwe ◆ Ingorane mu kwonka canke kwanka kwonka ◆ Ukwikomakoma bidakwiye kw’amaboko n’amaguru ◆ kugabanuka canke kuba sindabibazwa ku rwamo rwinshi cane canke k’umuco mwinshi ◆ kurira umwanya muremure utabona impamvu ◆ Kudahwa no gucibwamwo bishobora gutera umwumira Ku mezi atandatu ◆ Kudadarara canke ingorane mu gukomakoma amaguru n’amaboko ◆ Kutagumiza umutwe hamwe (bishobora kwerekana indwara y’amatwi, bishobora gutera indwara y’ukutumva igihe bitavuwe) ◆ kugabanuka canke kuba sindabibazwa ku majwi, ku masura y’abantu amenyereye canke kw’ibere ◆ Kwanka ibere canke ibindi bifungurwa ivyarivyo vyose Ku mezi cumi n’abiri ◆ Nta kintu na kimwe yishura, ◆ ntaraba ibintu bigendagenda ◆ Kubura umunezero no kutagira ikimenyetso na kimwe imbere y’uwumufasha ◆ Kubura akayabagu canke kwanka gufungura Ku myaka ibiri ◆ kutagira ikimenyetso na kimwe imbere y’uwundi muntu ◆ Ukudandabagirana igihe ariko aratambuka ◆ Ibikomere canke ihinduka ridasiguritse ry’inyifato (cane cane iyo umwana yasigiwe abandi bantu) ◆ Kubura akayabagu Ku myaka itatu ◆ Ntaryoherererwa gukina ◆ Kugwa hasi kenshi ◆ Ingorane mu gukoresha utuntu dutoduto n’iminwe ◆ Ingorane mu gutahura ubutumwa busanzwe abwiwe ◆ Ingorane mu gukurikiranya amajambo menshi iyo ariko aravuga ◆ Ukugabanuka canke ukubura ishaka ku mfungurwa Ku myaka itanu ◆ Ubwoba, ishavu, canke kugwana igihe ariko arakina n’abandi bana, bishobora kugaragaza ingorane z’ibishobisho canke ugukubagurwa Ku myaka umunani ◆ Ingorane mu kuronka no kugumana abagenzi, no kugira uruhara mu bikorwa vyo mu mirwi ◆ Guhagarika igikorwa canke agapfindo atabanje no kugerageza, canke ibimenyetso vyo kwihebura ◆ Ingorane mu kugaragaza ivyo ashaka, ivyo yiyumvira canke ibishobisho vyiwe ◆ Ingorane z’ukugumiza umutima ku gikorwa, gutahura no gushira mu ngiro igikorwa ciwe co kw’ishure ◆ Kugira ubukazi burenze hamwe no gutinya abagenzi canke umuryango birenze urugero Aho vyavuye: UNICEF, OMS, UNESCO, UNFPA, PNUD, ONUSIDA, PAM et Banque Mondiale (2010) 45 SU B Gufata inzoga n’ibiyayuramutwe bifise ingaruka mbi SUB Ukunywa inzoga canke ibiyayuramutwe (nka : « opiacés* », « héroine* », urumogi (« cannabis* »), « amphétamines* », « khat* », n’iyindi miti bandika nka « benzodiazépines* » na « tramadol* », kurashobora gutera ingorane zitandukanye. Twovuga cane cane ibimenyetso (bifatira ku mubiri canke mu mutwe bishika iyo hahagaritswe canke hagabanijwe cane ukubifata). Kubura amahoro utaronse ikiyayuramutwe n’ukukinywa mu gihe uzi ko kigufitiye ingaruka mbi (bitera indwara z’umubiri canke z’ubwonko canke zigahungabanya ukubaho neza muri rusangi). Ukunywa inzoga n’ibiyayuramutwe bigira ingaruka mbi iyo bitumye haba ibimenyetso vy’umubiri no mu mutwe, inyifato zitari nziza ku magara, ingorane z’imibano n’izo mu miryango, ihohoterwa rifatiye ku gitsina no ku mubiri, gukubagurwa n’ukutitabwaho ku bibindo, ingorane zijanye n’amahera n’ibindi bibazo bijanye n’ugukingirwa kw’abantu. Ibiharuro vyabafata inzoga n’ibiyayuramutwe bigira ingaruka mbi ku magara birashobora kwongerekana mu bihe vy’ubutabazi kubera abakuze n’imiyabaga bashobora kugerageza kurengera ibibahungabanya, ivyo batakaje canke ububabare mu kwivura*. Mu bihe vy’ubutabazi bukomeye, ukurondera inzoga n’ibiyayuramutwe kurashobora kubura, ari navyo bica bituma ibimenyetso bitari vyitezwe bitera ibibazo ubuzima bw’abantu bakoresha ivyo biyayuramutwe igihe kinini ku rugero rusa n’ururi hejuru. Ibi bintu ku nzoga ni ivyukuri kudaseswa. Iki kigabane kivuga ingaruka mbi zo kunywa inzoga canke ibiyayuramutwe kandi kirimwo icapa kungaruka k’ubuzima k’uwahagaritse inzoga (>> icapa SUB 1). Ku bindi navyo, ukunywa inzoga n’ibiyayauramutwe, raba ibigabane bijanye n’igitabu c’ubutabazi mhGAP gikwiye. Ibituma nyezina bivuza » Womenga asa n’uwuganzwa n’inzoga canke ibiyayuramutwe (akarorero kumota inzoga, asa n’uwaborewe, kutaguma hamwe, kubura inguvu, kutavuga neza, kutiyitaho, kuvyimba canke gukanashwa* kw’imbonero z’ijisho) » Ibikomere vya vuba » Ibimenyetso bijanye no gufata ibiyayuramutwe vy’inshinge (aho bateye inshinge, ubwandu bwo ku mubiri) » Gusaba imiti isinziriza canke y’ububabare Raba icapa gufata inzoga n’ibiyayuramutwe 1 co ku rupapuro rwa 49 rwerekeye gusuzuma no kuvura ingaruka mbi ku buzima zivuye ku guhagarika bukwinabukwi inzoga. 46 SU B Ugusuzuma Ugusuzuma – ikibazo 1 : ugufata inzoga canke ibiyayuramutwe vyoba bifise ingaruka mbi ku magara y’umubiri canke yo mu mutwe na/canke imibereho myiza y’umuntu muri rusangi ? » Tohoza ugufata inzoga n’ibiyayuramutwe, wirinde kwagiriza. » Baza ku vyerekeye : ◆ Urugero n’uburyo bwo kubifata  Muranywa inzoga ? Niba arivyo, zimeze gute ? Ibirahuri bingahe ku munsi / indwi ? Murafata imiti yo gusinzira, yo kurwanya uruhagarara/y’ububabare ? Umurwi uwuhe ? kangahe ku munsi/ku ndwi ? Hari ibiyayuramutwe mufata bitemewe n’amategeko ? Vy’ubwoko ubuhe ? mubifata gute : biciye mu kanwa, mu nshinge canke mu mazuru ? Incuro zingahe ku munsi/ku ndwi ? ◆ Ivyatumye munywa inzoga canke ibiyayuramutwe N’igiki gituma munywa inzoga canke mufata ibiyayuramutwe ? ◆ Ivyago kuri we no ku bandi Ibikomere canke izindi ngorane z’amagara zivuye ku kunywa inzoga n’ibiyayuramutwe ∙ Hari ibibazo mwagize vy’amagara kuva aho mutanguriye kunywa inzoga canke ibiyayuramutwe ? ∙ Mwoba mumaze gukomereka kubera mwanyoye inzoga canke ibiyayuramutwe ? Mwarabandanije kunywa inzoga n’ibiyayuramutwe naho bari barababwirije kubihagarika ∙ Naho umukenyezi yari yibungenze canke yonsa ∙ Naho uyo muntu yarazi ko kunywa inzoga n’ibiyayuramutwe bitera indwara z’umushishito n’igitigu ∙ Naho uyo muntu yafata imiti izirana n’inzoga canke ibiyayuramutwe, nk’iyisinziriza, imiti y’ububabare n’iyigituntu. Ingorane zo mu mibano zivuye ku kunywa inzoga canke ibiyayuramutwe : ∙ Ingorane z’amahera n’iz’ubutungane ∙ Mwarigeze kugira ingorane z’amahera canke kurenga amategeko kubera ukunywa inzoga n’ibiyayuramutwe ? ∙ Ingorane mu kazi ∙ Mwoba mwaratakaje akazi canke mugafatwa nabi ku kazi kubera kunywa inzoga canke ibiyayuramutwe ? ∙ Kutoroherwa mu kwitaho abana canke abandi mujejwe ∙ Mwoba mutorohewe kwitaho ibibondo vyanyu/ akazi kanyu kubera kunywa inzoga canke ibiyayuramutwe ? ∙ Guhohotera abandi ∙ Mwoba mumaze gukomeretsa umuntu iyo mwanyoye inzoga canke ibiyayuramutwe ? ∙ Ingorane za mwe n’uwo mwubakanye ∙ Ukunywa inzoga canke ibiyayuramutwe kwanyu vyoba vyaratumye haba ingorane mu rugo rwanyu ? » Kora vyihuta igipimo c’umubiri kugira urondere ko hari ibimenyetso vyerekana ko yanyoye kuva kera inzoga canke ibiyayuramutwe ◆ Ukuvirirana kw’ahaca infungurwa  ububabare bwo munda amaraso muvyo adashwe amaraso mumazirantoke canke amazirantoke yirabura ◆ Indwara y’igitigu Igeze kure : amaso asa n’umuhondo, urusina*, igitigu n’urwagasha bivyimvye kandi bigumye, ubwandu bw’ubwonko bivuye ku gitigu* ◆ Indwara zo gufungura nabi, gutakaza ibiro ◆ Ibimenyetso vy’ubwandu bivuye kugukoresha ibiyayuramutwe (nk’umugera wa SIDA, (Indwara y’igitugu itewe n’umugera B na C, ubwandu bwaho bateye urushinge ku mubiri n’igituntu). » Suzumira rimwe ukunywa inzoga bifise ingaruka mbi ku magara y’umuntu n’ugufata ibiyayuramutwe kuko ivyo kenshi bibera rimwe. 47 SU B Indinganizo z’ubufasha nshimikiro 1. Kuvura ibihungabanya amagara bivuye ku gufata inzoga n’ibiyayuramutwe » Gutanga ubufasha bwo kwa muganga bukenewe mu kuvura ingaruka mbi z’inzoga n’ibiyayuramutwe zifatiye ku mubiri. » Kuvura izindi indwara zose zo mu mutwe asanganywe, nk’ukuyinga n’akabonge, uguhahamuka n’indwara zo mu mutwe zeruye (>> DEP, ESPT, PSY). » Gutorera umuti inkurikizi zifatiye ku mibano zihuta ( nk’ukwitura inzego zijejwe kukinga abakubaguwe nk’ ihohoterwa rifatiye kugitsina. 2. Suzuma ugushaka kw’umuntu kwo guheba canke kugabanya kunywa inzoga canke ibiyayuramutwe » Raba neza ko uyo muntu afata inzoga n’ibiyayuramutwe nk’ingorane kandi ko yiteguriye kugira ico akoze kuri ico. ◆ Mwibaza ko mwagize ingorane y’inzoga canke y’ibiyayuramutwe ? ◆ Mwarigeze mwiyumvira guheba canke kugabanya ukunywa inzoga canke gufata ibiyayuramutwe ? ◆ Mwarigeze mugerageza guhagarika canke kugabanya ukunywa inzoga canke gufata ibiyayuramutwe ? 3. Guhimiriza umuntu guhagarika canke kugabanya ukunywa inzoga canke gufata ibiyayuramutwe » Tangura ikiyago kigufi gitera intege ku ngaruka mbi z’ukunywa inzoga no gufata ibiyayuramutwe : ◆ Baza umuntu ibibazo vyerekeye akamaro n’ingaruka mbi yibaza kuri ivyo anywa. Ntumucire urubanza ariko gerageza gutahura ikimutuma anywa ibintu nk’ivyo. Ni igiki kikuryohera ukura mu kunywa inzoga canke gufata ibiyayuramutwe ? Hari ibibi mubona bijanye n’ivyo munywa ? Mwoba mumaze kwicuza ko mwatanguye kunywa inzoga canke gufata ibiyayuramutwe ? ◆ Kunebagura ivyiza birengeje umuntu yibaza ko akura mu kunywa inzoga canke gufata ibiyayuramutwe. Iyo umuntu anywa ibiyayuramutwe kugira yibagire ingorane, mubaze : Kwibagira ingorane niwo muti nyawo ? Ivyo biratuma izo ngorane zihera ? ◆ Gushira imbere bimwe mu bibi biva ku kunywa inzoga n’ibiyayuramutwe bishobora kuba vyanebaguwe n’umurwayi. Mukoresha amahera angahe kugira muronke inzoga canke ibiyayuramutwe ? Ku ndwi ? Ku kwezi ? Ku mwaka ? N’iki kindi mwoshobora gukoresha ayo mahera ? ◆ Tanga izindi nsiguro kungaruka mbi z’inzoga n’ibiyayuramutwe ziboneka mu mwanya muto n’umwanya munini. Inzoga n’ibiyayuramutwe birashobora gutera ingorane zihambaye z’amagara y’umubiri nayo mu mutwe, cane cane nk’ibikomere n’ukwizizirwa n’ibiyayuramutwe. ◆ Tahura ko bigoye guhagarika canke kugabanya inzoga n’ibiyayuramutwe, kwubahiriza ingingo yifatiye, gusaba umurwayi ko yogaruka uwundi munsi. Tahuza umrwayi ko mwifuza kumufasha. Himiriza abantu ko gufata ingingo bo nyene yo guhagarika inzoga n’ibiyayuramutwe ari iciyumviro ciza. ◆ Iyo umuntu atiteguriye guhagarika canke kugabanya inzoga n’ibiyayuramutwe kwubahiriza ingingo yifatiye, musabe azogaruke uwundi munsi mubivugane. » Subiramwo amajambo atera intege yasiguwe mu vyirwa vyinshi twabonye. 4. Ganira uburyo butandukanye bwo kugabanya canke guhagarika ugufata ibiyayuramutwe bibangamira amagara y‘abantu » Ganira ubuhinga bukurikira : ◆ Kutagumiza inzoga canke ikiyayuramutwe mu nzu, kwirinda kuja mu bibanza abantu bashobora kunywa inzoga canke ikiyayuramutwe. ◆ Gusaba ugushigikirwa n’abafasha n’abagenzi. ◆ Gusaba abafasha guherekeza umurwayi ku masango yo gukurikiranwa. ◆ Gukundisha ibikorwa vyo mu kibano bitarimwo inzoga canke ikiyayuramutwe. » Tegekanya, iyo bishoboka, ukwitura imirwi y’ugushigikirana ku bantu basangiye ikibazo co kunywa inzoga canke gufata ibiyayuramutwe. » Iyo umurwayi yemeye guhagarika kunywa inzoga canke ikiyayuramutwe, mubwire ko bishoboka ko agira ibimenyetso vy’umubiri (ikiringo kingana n’indwi imwe). Gusigura ivyo bimenyetso (nk’uruhagarara rwo mu mutima, ukwiyambagura inyuma yo gufata ibiyayuramutwe vyitwa « opiacés, benzodiazépines » be n’inzoga). Hanura umurwayi kuzogaruka kw’ivuriro mu gihe ivyo bimenyetso vyogaragara cane. 48 SU B 6. Tegekanye ikurikirana ritunganijwe » Bandanya gutanga ubufasha, sigura kandi korera hamwe n’umurwayi n’abafasha kuvyerekeye ubushobozi bwo kugabanya canke guhagarika inzoga canke ikiyayuramutwe. » Ringaniza kandi tegura amahwaniro atunganijwe kugihe bijanye n’indinganizo z’ubufasha (>> ingingo ngenderwako). 5. Tanga ubufasha bw’imico n’imibano nkuko bisiguye mu ngingo ngenderwako yo kugabanya uruhagarara no gukomeza ubufasha mukibano (>> ingingo ngenderwako z’ubuvuzi) » Kwitwararika ibitera uruhagarara mu nyifato n’imibano bihari. » Komeza ubufasha mu kibano. » Kwigisha ubuhinga bwo kugabanya uruhagarara. 49 SU B Icapa gufata inzoga n’ibiyayuramutwe 1 Gusuzuma no kuvura ibimenyetso bibangamira ubuzima bishikira uwahagaritse inzoga Ibituma nyezina bibangamira cane ubuzima bitera uwahagaritse inzoga yitura abaganga » Ukwiyambagura, uguhagarika umutima bikomeye » Gucanganyikirwa, kumva canke kubona ivyabandi batumva canke ngo babone*, kwiyumvamwo ibitarivyo » Ibisahuzi » Ivumbuka ry‘umurindi w’amaraso (akarorero ibiharuro biri hejuru ya 180/100mmhg) canke umutima utera ku rugero rwo hejuru (nk’akarorero indihagizi y’umutima irenza 100 ku munota) Gusuzuma inkwirikizi zibangamiye ubuzima zo guhagarika inzoga Gusuzuma : ikibazo 1 : vyoba bivuye ku guhagarika inzoga ? » Rondera kandi vura ibindi bituma bishobora gusigura ibimenyetso bikurikira : ◆ Inyonko (malaria), umugera wa SIDA, ubundi bwandu, isanganya ryo mu mutwe, ihungabana ry’umubiri* (nk’igabanuka ry’isukari*, igabanuka ry’ivyunyunyu*) ukuvuga ibitarivyo canke gutakaza ubwenge bivuye ku ndwara y’igitigu, umwingo*, indwara ifatira kw’ihungabana ry’udutsi dusoza amaraso yo mu bwonko, gufata ibiyayuramutwe, kuba warigeze kurwara indwara yo mu mutwe yeruye canke y’intandara. » Iyo ivyo bitera ivyo bimenyetso batabitoye, tohoza ku vyerekeye kunywa inzoga mu kubaza ibibazo umurwayi n’abamuherekeje : ◆ Uyo muntu aranywa inzoga ? ◆ Ni ryari yanyoye ubwanyuma ? ◆ Anywa izingana gute mu bisanzwe ? » Ibimenyetso bijanye no guhagarika inzoga iyo vyaje iminsi yakurikiye ihagarikwa ritunganijwe rya cane ry’inzoga. Bishika mubisanzwe umunsi umwe canke ibiri inyuma yo kunywa ikirahuri canyuma. ◆ Iyo umuntu agize ibisahuzi canke akabona, akumva ivyo abandi batumva, kandi iyo uguhagarika inzoga bitiketswe, rondera indwara y’intandara (>> EPI) canke indwara yo mu mutwe yeruye (>> PSY). Ugusuzuma : Ikibazo ca 2 : iyo umuntu afise ibimenyetso vyo guhagarika inzoga, vyoba bibangamiye ubuzima bwiwe ? » Rondera ibimenyetso bibangamiye ubuzima : ◆ Ibisahuzi (muri rusangi mu masaha 48) ◆ Ibimenyetso vy’ivyo umurwayi yemera bitari vyo bitandukanye n’ivyo abandi bemera* (muri rusangi mu masaha 96) gucanganyikirwa vy’umushuhira, kutamenya ikibanza arimwo n’igihe agezemwo kubona canke kumba abantu canke ibintu bitahari » Suzuma ko umuntu ashobora kugira ingaruka mbi zikurikira zishobora kumutwara ubuzima zijanye no guheba inzoga (ibisahuzi canke ukuba mu kuri yisangije wenyene) mu munsi 1 canke 2 ikurikira : ◆ Ukuba yarigeze guhagarika inzoga bigahakwa kumutwara ubuzima (ibisahuzi, ukuba mu kuri yisangije wenyene) canke ◆ ibimenyetso bigaragara bijanye n’uguhagika inzoga : ukwiyambagura cane, ukurakara, uguhungabana bikabije kubira icuya kiregeje, kujugumira ibikonjo ivumbuka ry’umurindi w’amaraso (akarorero : ibiharuro biri hejuru 180/100mmhg canke umutima ukiruka (hejuru y’incuro 100 ku munuta). Iyo hiketswe ko umuntu asigaye ari mu kuri yisangije wenyene kubera inzoga, koresha indinganizo y’ubutabazi bwihuta kubahevye inzoga bigahakwa kubatwara ubuzima (raba musi) hanyuma mutegekanye ikete rimuha uburenganzira bwo kuja kubitaro bimwegereye. Indinganizo y’ubufasha bwihuta kuvyerekeye guhagarika inzoga bishobora guhitana ubuzima 1. Vura ubwo nyene uguhagarika inzoga n’umuti witwa « diazépam » (>> icapa SUB 1) » Urugero rw’ umuti ruvana n’akamenyero* umuntu afise ka dazepam, k’ubukomezi bw’ibimenyetso bijanye no guheba inzoga, hamwe n’indwara z’umubiri asanganywe. ◆ Tanga urugezo rw’umuti bivanye n’ibimenyetso mwabonye. Urugezo rwemewe n’urutanga agatiro gakeya. Urugero ruri hejuru rurashobora gutera ugusinzira umwanya munini harimwo ingorane zijanye no guhema bukebuke cane. Suzuma cane incuro zijanye no guhema n’urugero rw’ugusinzira kw’umuntu. Urugezo rutoyi rw’umuti rurashobora gutuma umurwayi agira ibisahuzi/kuba mukuri kwiwe wenyene. » Genzura kenshi ibimenyetso bijanye n’uguheba inzoga (ku masaha 3 canke 4). Bandanya gukoresha diazépam gushika ibimenyetso bizimanganye (kenshi musi y’iminsi 3 canke 4 utarengeje iminsi 7). » Iyo ibisahuzi biboneka umuntu yahagaritse inzoga, NTIMUTANGE umuti w’intandara. Bandanya Diazépam. » Ibimenyetso bijanye no kuba mukuri kwiwe nko gucanganyikirwa, ukwiyambagura canke akabona canke akumva ibitariho, birashobora kubandanya indwi nyinshi ibindi bimenyetso bijanye n’uguhagarika inzoga vyaheze. Muri ico gihe, tegekanya kumira imiti y’indwara zo mu mutwe zeruye nka « halopéridol » hagati ya mirigarama 2,5 na 5 gushika kuri gatatu ku munsi gushikaho ivyo bimenyetso bihera. Mu bihe bimwe bimwe, indwi nyinshi zirashobora gukenerwa kugira ivyo bimenyetso bihere. Mwirinde gusinziriza umurwayi cane. » Bishoboka, tegekanya ahantu hatekanye, hadahungabanya kandi habona neza. Gerageza iminsi yose habe umuco, naho hoba mw’ijoro mukwirinda ko umuntu aja aravyuka hagati mw’ijoro.Tegekanya gushira umuntu ku matera iri hasi mukwirinda ko akomereka. Bishoboka, saba kugumana nawe kandi mumucunge. Bishoboka, irinde kumuboha. 2. Vura ugufungura nabi » Tanga vitamine B1 « thiamine » mirigarama 100 ku munsi mu kanwa iminsi itanu. » Suzuma kandi vura indwara zijanye no gufungura nabi. 3. Kugumiza urugero rw’amazi akwiye mu mubiri » Bishoboka, vura umwumira mukoresheje iserumu. » Himiriza kunywa ibintu vyinshi (n’imiburiburi amaritiro 2 gushika kuri 3 ku munsi). 4. Iyo ibimenyesto vyo guhagarika bishobora guhitana ubuzima vyaheze, tegekanya ugusuzuma n’ukuvura ukunywa inzoga vyonona amagara y’umuntu hamwe n’ibiyayuramutwe (raba mu gisomwa c’iki kigabane). 50 SU B Icapa gufata inzoga n’ ibiyayuramutwe 1: ugukoresha Diazépam mu gihe uguhagarika inzoga bibangamiye ubuzima Diazépama Urugero rw’ibanze Hagati ya miligarama 10 na 20 gushika kuri 4 ku munsi Urugero rukurikira Gabanya bukebuke urugero rw’umuti canke incuro iyo ibimenyetso vyaheze Cungera kenshi, kuko umuntu wese yakira ugutandukanye kuruyo muti Uburyo ifatwa Mukanwa Inkurikizi mbi zikomeye (ziboneka gake) Uguhema nabi*, ihungabana rikomeye ry’ubwenge, Ihungabana rijanye n’ukugaba : suzuma kenshi uko umuntu ahema n’urugero rwo gusinzira Inkurikizi mbi z’imiti zikunze kwibonekeza Ukwisinzirirako, ukwibagira, ihungabana rikomeye ry’ubwenge, ugutakaza inguvu kw’imitsi, ihungabana mu kugaba : ntimuhe umuntu uwundi muti iyo yisinzirirako Ukwiyubara ku bantu bafise ivyo bisangije Tanga icakane c’umuti ku bantu bakuze Ntimuwukoreshe ku bantu bafise ingorane zo guhema a Tubisanga mubitegekanijwe vya nkenerwa vy’ubuvuzi bwihuta bwo mubitato nkuko vyemejwe n’ishirahamwe mpuzamakungu « OMS, 2011 » 51 SU I Ukwiyahura SUI Indwara zo mu mutwe, intuntu bukwinabukwi n’ukwihebura birakunda kwibonekeza mu bihe vy’ubutabazi. Izo ngorane zirashobora gutuma kwiyahura* canke kwigirira nabi*. Bamwe mubavuzi barihenda bagatinya ko kuvuga kwiyahura vyohava bituma uwo muntu aca yiyahura. Ahubwo, kubivuga bigabanya kenshi uguhungabana kw’umuntu kujanye n’ivyo vyiyumviro vyo kwiyahura, bimufasha kwumva ko atahuwe kandi bikamuha n’umwanya wo gusesangura ibijanye n’ukwiyahura. Abakuze n’imiyabaga barwaye imwe mu ndwara zo mu mutwe, z’udutsi nsozabwenge canke iziterwa n’ibiyayura mutwe (MNS) zivugwa muri iki gitabo barashobora kwiyahura canke bakigirira nabi. Ibituma nyezina vyokubonana n’umuganga k’umuntu ashobora kwiyahura canke kwigirira nabi Kwumva agahinda canke guhungabana birenze urugero Umubabaro n’ukwihebura birenze UKuba yaragerageje kwigirira nabi muri kahise (nko kwiha imiti yica udukoko, kunwa imiti irengeje urugero, kwibabaza ku mubiri) 52 SU I Ugusuzuma - Ikibazo 1 : Umuntu yoba yaragerageje kwiyahura canke kwigirira nabi muri iyi minsi iheze ? Ugusuzuma » Suzuma ibi bikurikira : ◆ Kurya ishano, kumererwa nabi kubera inzoga / ibiyayuramutwe, gufata imiti irengeje urugero canke ubundi buryo bwo kwigirira nabi Ugusuzuma - Ikibazo 2 : Hoba hari icerekana ko umuntu ahava yigirira nabi canke yiyahura ? » Baza umuntu /canke abamuherekeje ku vyerekeye : ◆ Ivyiyunviro canke integuro yo kwiyahura (muri uwo mwanya canke mukwezi guheze) ◆ Ibikorwa vyo kwigirira nabi mu mwaka uheze ◆ Kuronka vyoroshe ivyo ashobora gukoresha mu kwiyahura (nk’imiti yica udukoko, umugozi, ibigwanisho, imbugita, imiti yanditswe na muganga canke ibiyayuramutwe). » Rondera ibimenyetso vyo :  ◆ Kwihebura canke intuntu y’umushuhira ◆ Inyifato y’ubukazi canke kwiyambagura birenze ◆ Kwigunga canke kwirinda kuvugana n’abandi. » Umuntu afatwa nk’uwushobora kwiyahura canke kwigirira nabi ubwo nyene mu gihe : ◆ Afise ivyiyumviro, imigambi canke inyifato yo kwiyahura, canke ◆ Yarigeze kugira ivyiyumviro, imigambi n’inyifato muri kahise yo kwigirira nabi mu kwezi guheze canke ibikorwa vyo muri iyo ntumbero mu mwaka uheze ku muntu afise muri uwo mwanya ukwiyambagura birenze, akaze, atuntuye canke adashaka kuvuga. Gusuzuma-Ikibazo 3 : Hari izindi ndwara yoba asanganywe ziyongera kuri iyo nyifato yo kwiyahura canke kwigirira nabi ? » Suzuma wongere uvure indwara zishoboka asanzwe agendana : ◆ Gutakaza ubushobozi canke ububabare budahera (nk’akarorero bwatewe n’ibikomere vyo ku mubiri vya vuba mu gihe c’ubutabazi). ◆ Indwara yo kuyinga/akabonge (>> DEP) ◆ Indwara yo mu mutwe yeruye (>> PSY) ◆ Kunwa inzoga canke ibiyayura mutwe vyonona umubiri (>> SUB). ◆ Ihahamuka (>> ESPT) ◆ Intuntu y’umushuhira (>> STR, DEU, AUT). Icapa SUI 1 : Bavuga gute ibikorwa vyo kwiyahura canke kwigirira nabi 1. Rondera ahantu hatekanye kugira umuntu agire ukwizera. » kudacira urubanza umuntu ku nyifato ziwe zo gushaka kwiyahura. » Hitishamwo umuntu ko mwovugana wenyene canke ari kumwe n’abandi bantu yishimiye. 2. Koresha urutonde rw’ibibazo aho ikibazo cose kikujana ku kindi. Nk’akarorero : » [Tangura muri kubu] Mwiyumva gute ? » [Fata nka nkama ibigumbagumba vy’umuntu] Mumeze nkababaye/bahungabanye. Turashobora kubivuganako ? » Mwiyumvira gute kazoza kanyu ? Mukitezeko iki ? » Abantu bamwe bamwe bagize ivyo bibazo bambwiyeko biyumvira kw’atakamaro ko kubaho. Muryama ku mugoroba mwifuza kutazosubira kwikangura ? » Muramaze kwiyumvira kwigirira nabi ? » Muramaze gutegura kwiyahura ? » Hamwe vyoba arivyo, mu buryo ubuhe ? » Murafise ivyo mwokoresha mu kwiyahura ? » Mumaze kwiyumvira kubikora mu mwanya uyuhe ? » Muramaze kugerageza kwiyahura ? 3. Hamwe umuntu yoba amaze kubabwira ivyiyumviro vyo kwiyahura : » Gumana inyifato itekanye kandi ihumuriza. » Kirazira kwemera ivyudashitsa. ◆ Ibimenyetso bisaba ubuvuzi bwo kwa muganga bwihuta Kuvirirana bivuye ku kwitemagura Gutakaza ubwenge Itiro ryinshi rifatanije no kubura inguvu 53 SU I 1. Mu gihe umuntu yagerageje kwiyahura, muhe ubufasha bw’ubuvuzi, cungera wongere utange ubufasha bw’inyifato n’imibano bukenewe » Tanga ubufasha bw’ubuvuzi : ◆ Fata abantu bigiriye nabi nk’uko mufata abandi, mwubahirije agateka kabo. Ntimubahane. ◆ Vura ibikomere vyo ku mubiri canke ishano. Mu gihe ahejeje kunywa imiti yica udukoko, raba igitabo c’ishirahamwe mpuzamakungu ryitaho amagara OMS kubijanye n’ubufasha bw’uwanyoye imiti yica udukoko (OMS, 2008). » Mu gihe yanyoye imiti yanditswe na muganga irengeje urugero, iyo imiti igikenewe, hitamwo iyifise ingaruka mbi nke zishoboka. Iyo bishoboka, kwandika umuti mushasha ku biringo bitoyi gusa (nk’akarorero, iminsi mikeyi gushika ku ndwi) kugira ukinge gusubira gufata imiti ku rugero rurenze. Indinganizo y’ubufasha nshimikiro » Bandanya ucungera umuntu mu gihe gushaka kwiyahura bikibandanya (raba inyuma y’aha kugira muronke insiguro nyinshi). » Gutumirira ubufasha bw’inyifato n’imibano (raba inyuma y’ibi kugira muronke insiguro nyinshi). » Iture umuhinga mu magara yo mu mutwe, igihe yoboneka. 2. Nimba hariho uguhakwa kuboneka kwo kwigirira nabi canke kwo kwiyahura, cungera wongere utange ubufasha bw’inyifato n’imibano » Cungera uwo muntu : ◆ Rondera ahantu hatekanye kandi hahumuriza Egeza kure ibintu vyose bishoboka ashobora gukoresha mu kwigirira nabi/kwiyahura, gutumirira kuja mu nyubako itekanye kandi iri ukwayo. Yamara, kutamureka wenyene. Abarwaza canke abavuzi bategerezwa kugumana nawe umwanya wose. ◆ Muri rusangi, NTIMUBASHIRE mubisata vy’indwara zisanzwe kugira murinde ibikorwa vyo kwiyahura. Abakozi bo mu bitaro bahakwa kudashobora kucungererayo umuntu yashatse kwiyahura. Yamara, hamwe gushirwa mu bitaro mu bisata vy’indwara zisanzwe vyoba nkenerwa kugira avurwe inkurikizi zo kwa muganga zitewe n’ukwigirira nabi, mucungerere hafi kugira ukinge kwadasubira kwigirira nabi ari mu bitaro. Ahariho hose, menya neza ko umuntu acungerewe amasaha 24h kuri 24 gushik’aho ugushaka kwiyahura bihera. » Tanga ubufasha bw’inyifato n’imibano : ◆ NTUTANGURE gutanga inyishu zishoboka ku ngorane z’umuntu. Gusubira kumuha umwizero. Nk’akarorero : Abantu benshi baciye mu bihe bisa n’ibi (bumva batakaje umwizero, canke bifuza gupfa) bahavuye basanga hariho umwizero, n’ibigumbagumba vyabo vyagiye bimera neza uko umwanya ugenda. ◆ Fasha umuntu kurondera ibituma yoguma ari muzima. ◆ Ronderera hamwe inyishu z’ibibazo. ◆ Guhimiriza abafasha, abagenzi, n’abandi bantu bizewe hamwe n’ubufasha bwo mu kibano mu gucungera no gushigikira umuntu mu gihe c’ibimenyetso nyezina vyo kwiyahura. Basigurire akamaro ko gucungera umuntu amasaha 24 kuri 24. Raba ko bafise indinganizo yikwije kandi ishoboka (nk’akarorero ninde azocungera umuntu mu kiringo kanaka co kumurango). ◆ Tanga ubufasha bw’inyifato n’imibano bwiyongera nk’uko biri mu ngingo ngenderwako zo kugabanya uruhagarara no kwongereza ubufasha bw’ikibano (>> Ingingo ngenderwako z’ubuvuzi). » Iture umuhinga yanonosoye ivy’amagara yo mu mutwe, hamwe yoba ahari. 3. Shigikira abafasha, wisunze uko biri mu ngingo ngenderwako zo kugabanya uruhagarara no kwongereza ubufasha bw’ikibano (>> Ingingo ngenderwako z’ubuvuzi) » Raba ko hakozwe indinganizo ikwiye yo gukurikiranwa kwa muganga n’uko abafasha bagira uruhara muri iryo kurikiranwa (>> ingingo y’ubufasha mu ngingo ngenderwako z’ubuvuzi). » Kugumana imigenderanire itegekanijwe (kw’iterefone, ukumusanga muhira) n’umurwayi. » Kurikirana kenshi mu ntango (nk’akarorero, 1 kundwi mu mezi 2 yambere) hanyuma ugabanye incuro mu gihe yatoye mitende (bur’indwi 2 gushika kuri 4). » Mukurikirane igihe kirekire mu gihe cose ugushaka kwiyahura bikibandanya. Mu gihe cose mubonanye, suzuma ivyiyumviro n’imigambi vyo kwiyahura. 4. Kugumana imigenderanire n’ikurikirana ritunganijwe

55 A U T Izindi ndwara zihambaye z’amagara yo mu mutwe AUT Muri kino gitabo, tuzovuga indwara nyamukuru MNS dusanga mu bihe vy’ubutabazi bw’abantu. Yamara, ntitwashizemwo indwara zose zishoboka zihungabanya amagara yo mu mutwe. Iki kigabane rero gifise intumbero y’ubuhanuzi nshimikiro mu bufasha bw’intango bw’abakuze, imiyabaga n’abana bafise ibibazo bihungabanya amagara yo mu mutwe iki gitabo kitavuga ahandi. Izindi ndwara z’amagara yo mu mutwe zirimwo : (a) ibimenyetso bitandukanye vy’umubiri bidatewe n’ingorane zo mu mubiri (b) ihindagurika ry’imero n’inyifato bihagarika umutima ariko bidakwiza ibifatirwako mu ndwara zivurwa mu bindi bigabane vy’iki gitabu. Hashobora cane cane kuba ari indwara y’ukuyinga canke izindi ndwara zitaragaragara. Izo zindi ndwara zihungabanya amagara yo mu mutwe zifatwa nk’izihambaye iyo zihungabanya ibikorwa canke iyo umuntu arondera ubufasha kugira azivuze. 56 A U T Ugusuzuma - ikibazo ca 1 : hoba hari igituma gifatiye ku mubiri gishobora gusigura neza ibimenyetso ? » Vura igituma cose gifatiye ku mubiri kigaragara kandi subiramwo gusuzuma ko ibimenyetso bibandanya. Ugusuzuma » Suzuma muri rusangi uko amagara yiwe y’umubiri yifashe mu gukoresha ibipimo vyo kwa muganga bibereye. Ugusuzuma - ikibazo ca 2 : Yoba ari indwara MNS twize mu kindi kigabane c’iki gitabu ? » Rondera kuvangura : ◆ Ibimenyetso bikomeye vy’uruhagarara rw’umushuhira rwo mu mutima (>> STR) Ibifatirwako nyamukuru : ∙ umuntu yarabaye mu gihe gishobora kuba nsenserezamutima muri uku kwezi guheze. ∙ ibimenyetso vyaje inyuma y’ico gihe ∙ umuntu aragira ibibazo vyinshi mu kurangura imirimo ya minsi yose, bivuye kuri ivyo bimenyetso canke yituye ubuvuzi kubera ivyo bimenyetso nyene. ◆ Ibimenyetso bikomeye vy’ikigandaro (>> DEU) Ibifatirwako nyamukuru : ∙ ibimenyetso vyagaragaye inyuma y’ukubura gukomeye ∙ umuntu aragira ibibazo vyinshi mu kurangura imirimo ya minsi yose, bivuye kuri ivyo bimenyetso canke yituye ubuvuzi kubera ivyo bimenyetso nyene. ◆ Indwara y’ukuyinga n’akabonge (>> DEP) Ibifatirwako nyamukuru (indwi zibiri n’imiburiburi) : ∙ imero y’umubabaro ugumaho ∙ ukugabanuka kw’ugushaka n’umunezero mu bikorwa na cane cane ivyo yahora akunda ∙ umuntu aragira ibibazo vyinshi mu kurangura imirimo ya minsi yose, bivuye kuri ivyo bimenyetso canke yituye ubuvuzi kubera ivyo bimenyetso nyene. ◆ Ihahamuka (>> ESPT) Ibifatirwako nyamukuru : ∙ igihe gishobora kuba nsenserezamutima carabaye ikiringo kirenga ukwezi  ∙ indoto ziteye ubwoba zisubiriza, igarukagaruka ry’ivyo yabonye, ivyibutso vy’ivyabaye bijanye na ca gihe nseserezamutima vyitamwo mu vyiyumviro vyiwe bijanye no kugira ubwoba bwinshi ∙ kwirinda nkana ikintu cose cibutsa ca gihe nseserezamutima ∙ kuguma yiteze icago comushikira ukwiyumvira canke ukwama agavye arindiriye icago canke ukutihanganira urwamo rutitezwe) ∙ umuntu aragira ibibazo vyinshi mu kurangura imirimo ya minsi yose, bivuye kuri ivyo bimenyetso canke yituye ubuvuzi kubera ivyo bimenyetso nyene. ◆ Ukunywa inzoga n’ibiyayuramutwe bibangamira amagara y’abantu (>> SUB) Ibifatirwako nyamukuru : ∙ ukunywa inzoga n’ibiyayuramutwe bibangamira amagara yiwe na/canke y’abandi. ◆ Inyifato yo kwigirira nabi/kwiyahura (>> SUI) Ibifatirwako nyamukuru : ∙ ishirwa mu ngiro ry’inyifato yo kwigirira nabi ; ivyiyumviro n’imigambi yo kwiyahura ∙ ivyiyumviro, imigambi n’ukwigirira nabi muri kahise ka vuba ku muntu yiyambagura bikomeye, afise intuntu, adashaka kuvugisha abandi. » Iyo imwe muri zo ndwara zanditswe aho haruguru yiketswe, raba ku kigabane bihuriranye kugira isuzumwe yongere ivurwe. » Iyo 1) Ibituma bifatiye ku mubiri bitabonetse, 2) indwara zo mu mutwe, z’imitsi nsozabwenge n’izivuye kugufata ibiyayuramutwe zitabonetse kandi 3) umuntu afise ibibazo bikomeye mu kurangura imirimo ya buri munsi bivuye kuri ivyo bimenyetso canke yituye ubuvuzi kubera ivyo bimenyetso nyene, aba arwaye rero iyindi ndwara ihambaye yo mu mutwe. ◆ Harakenewe muri rusangi ukwisuzumisha kenshi kugira higizweyo ibituma bifatiye ku mubiri canke mu mutwe vyavuzwe hejuru. Ugusuzuma - ikibazo ca 3 : iyo uwakwituye ari umuyabaga, yoba afise ingorane mu nyifato ? » Baza umuyabaga n’abamuherekeje mu ntumero yo gusuzuma ingorane z’inyifato zimara umwanya munini canke zitwararitswe. Uburorero bumwe bumwe : ◆ Uguhohoterwa kwibonekeza ◆ Ugufata ibiyayuramutwe ◆ Ugukubagurwa canke ubundi bugizi bwa nabi akorera abagenzi ◆ Kumenagura ibintu ◆ Inyifato mpuzabitsina ishobora kubangamira amagara. » Iyo umuyabaga afise ingorane mu nyifato, baza ibindi bibazo ku vyerekeye : ◆ Ibintu bimuhagaritse umutima muri kino gihe canke muri kahise (ugufatwa ku nguvu nk’akarorero) ◆ Indero bahawe n’abavyeyi (indero nke canke abavyeyi bakaze cane, urukundo rudakwiye berekwa n’abavyeyi, abafasha barwaye indwara zo mu mutwe) ◆ Ico uwo muyabaga akora umwanya munini. Baza ibibazo bikurikira : iyo akora canke aja kw’ishure : Umwanya utaba uri ku kazi ntube kwiga uwukoresha gute ? Woba ukora ibikorwa bimwe bimwe buri gihe ? Urarambirwa kenshi? Iyo urambiwe ukora iki ? 57 A U T Indinganizo y’ubufasha nshimikiro 1. Mu bihe vyose (iyo umuntu yerekanye ibimenyetso vy’ingorane z’ibishobosho, vy’umubiri canke inyifato), tanga ubufasha bw’inyifato n’imibano nshimikiro nk’uko vyasiguwe mu ngingo zo kugabanya uruhagarara rwo mu mutima n’ugukomeza gushigikirana mu kibano (>> Ingingo ngenderwako z’ubuvuzi). » Kwitwararika ibintu bitera uruhagarara rw’inyifato n’imibano bihari. 2. Iyo atandwara n’imwe y’umubiri yabonetse kugira isigure ivyo bimenyetso vy’umubiri, fata ko ari vyo vy’ukuri kandi gerageza gutanga insiguro zishoboka. » NTIHAGIRE ibipimo musaba kiretse iyo hari igituma co kwa muganga kigaragara (nk’akarorero ibimenyetso vy’amagara bitameze neza). ◆ Ugusaba ibipimo bishobora gukomeza ibigumbagumba vyiwe ko afise ingorane y’umubiri. ◆ Ibipimo bishobora kugira ingaruka mbi zitari zitezwe. » Menyesha umurwayi ko ata ndwara n’imwe ikomeye yatowe. Muhe inyishu z’ibipimo bizima. ◆ Nta ngorane n’imwe ikomeye y’umubiri twatoye. Simbona icotuma tugira ibindi bipimo bishasha muri uyu mwanya. » Iyo umuntu ashimitse mu gusaba kandi ibipimo, tegekanya kumubwira : ◆ Ntitwipfuza kugira ibipimo bidakenewe kuko bishobora gutera ingaruka mbi n’uguhagarika umutima kudakenewe. » Tegera ko ivyo bimenyetso atari vyo yiyumvira kandi ko igihambaye ari kuvura ibimenyetso bitera intuntu. » Baza umuntu insiguro yiwe kubitera ivyo bimenyetso. Ivyo birashobora gutuma hikekwa icoba cabitumye, gufasha kwerekana ubwizigirwa n’uyo muntu ku buryo yemera gufashwa. » Sigura ko uruhagarara rwo mu mutima canke umubabaro w’ibishobisho bitera kenshi ibimenyetso vyo mu mubiri (ukubabara munda, ugukanashwa kw’umubiri, n’ibindi…). Vugana kw’isano riri hagati y’uruhagarara, ibishobisho n’ibimenyetso. » Himiriza ukubandanya imirimo ya minsi yose (canke ugusubira kuyikora uko iminsi igenda). » Koresha kandi ingingo zo kugabanya uruhagarara rwo mu mutima n’ugukomeza gushigikirana mu kibano. (>> Ingingo ngenderawko z’ubuvuzi). 3. Iyo uyo muntu ari umuyabaga afise ingorane z’inyifato » Fata akanya ko kwumviriza uko abona izo ngorane (bishoboka abamuherekeje muri kumwe). » Kwigisha umuyabaga n’abamuherekeje. Sigura ibi bikurikira : ◆ Imiyabaga iragira rimwe na rimwe ingorane mu nyifato iyo bashavuye, iyo ataco bariko barakora, iyo bari mu ruhagarara canke mu mubabaro, n’ugukomeza kubitaho no kubashigikira naho bafise iyo nyifato. ◆ Abafasha imiyabaga bategerezwa gukora ibishoboka vyose kugira bavugane n’imiyabaga, naho ivyo bigoye ◆ Ubutumwa bwagenewe abafasha : Gerageza murabe ibikorwa vyiza bihimbaye mushobora gukorera hamwe. Erekana neza ivyemewe n’ibibujijwe. Tera intege mwongere muhe agashimwe umuyabaga iyo yagize inyifato nziza, kandi mumuhanure gusa iyo inyifato ziwe ziteye ingorane zikomeye. Ntimwigere mukoresha ibihano bifatiye ku mubiri. Mushimire ku nyifato nziza ziwe hakumuhanira inyifato mbi. Ntimuvugishe umuyabaga mu bihe mushavuye cane. Rindira musubire kuronka ituze. ◆ Ivyo mubwirizwa kuvugana n’umuyabaga vyihariye : Hariho uburyo bwiza butorera inyishu kurambirwa, uguhagarika umutima n’ishavu’nk’akarorero ugukora imyimenyerezo canke ibikorwa rusangi. Birashobora kuba nkenerwa kwiganira abantu babizigirwa mu gihe c’ishavu, kurambirwa, guhagarika umutima n’umubabaro. Ukunyawa inzoga n’ibindi biyayuramutwe birashobora kwunyura ishavu n’ukuyinga ; bitegerezwa rero kwirindwa. » Himiriza kugira uruhara mu : ◆ Inyigisho itunganijwe mu buryo buzwi n’ubutazwi ◆ Ibikorwa biboneka, nkenerwa kandi vy’ingirakamaro muri rusangi (kwubaka uburaro nk’akarorero) ◆ Integuro itunganijwe neza yo kwinonora imitsi. » Gushira mu ngiro kandi ingingo zo kugabanya uruhagarara rwo mu mutima n’ugukomeza gushigikirana mu kibano (>> Ingingo ngenderwako z’ubuvuzi). Kw’iyo miyabaga n’ababafasha. » Komeza ubufasha mu kibano. » Kwigisha ubuhinga bwo kurwanya uruhagarara. 4. Ikurikirana » Hanura umurwayi ko yogaruka igihe ibimenyetso vyogumaho, vyokomera canke bitagishobora kwihanganirwa. » Iyo atagahengwe kabonetse canke umurwayi n’umurwaza basavye bashimitse ibipimo bishasha no kuronswa imiti, iture umuhinga. NTIMWANDIKE imiti mu kuvura izindi ndwara zihambaye z’amagara yo mu mutwe (Kiretse bivanye n’impanuro zatanzwe n’umuhinga). NTIMUTANGE inshinge z’amavitamine canke iyindi miti itaco imara. 58 5. Indwara z’ibishobisho/akabonye no kuyinga Mu buzima bwa minsi yose, inyifato y’umuntu irahungabana cane mu kiringo kirenza indwi zibiri hibonekeza : a) umubabaro/kwigonya, na/ canke b) guhagarika umutima/ ubwoba burengeje kandi butarengerwa. Imigenderanire n’abantu, akayabagu, itiro no kwitwararika ivyo arimwo kenshi birahungabana. Ashobora kwidoga ko arushe cane kandi akigunga, aguma aryamye umwanya munini k’umusi. Ivyiyumviro vyo kwiyahura biba bihari kenshi. Uwo murwi ugizwe n’abantu bafise ubwoko bw’indwara y’akabonge itera gutakaza ubushobozi bwo gukora no kwiyumvira, indwara zo guhagarika umutima no guhahamuka (zirangwa n’ibimenyetso vy’igarukagaruka, vyo kwirinda no kugaba birengeje). Ingero ziri hasi cane yizo ndwara ziri mu murwi « Izindi ndwara z’inyifato ». 6. Izindi ndwara z’inyifato Uwo murwi ugizwe n’indwara zifatiye ku bishobisho (nk’akarorero imero yo kuyinga, guhagarika umutima), ku vyiyumviro (ivyiyumviro bidahera, kutitwararika ibikorwa ariko arakora) canke ku nyifato (kwigonya, ubukazi, kwirinda). Umuntu aba ameze nk’uwushobora gukora ibikorwa vyose canke vyinshi mu bikorwa vya minsi yose bisanzwe. Ikimuraje ishinga ni ibimenyetso vy’indwara z’ibishobisho zitababaza cane (nk’akarorero kuyinga k’urugero rubayabaye, guhagarika umutima canke guhahamuka) canke akavyerekeza ku ngorane zisanzwe (ni kuvuga atandwara y’ukuri ihari). Ivyo gufatirako : Uwo murwi uzofatirwako gusa igihe a) igihe umuntu asavye ubufasha, b) igihe umuntu atari mu muce n’umwe muri iyo itanu yavuzwe aho hejuru. 7. Indwara z’umubiri zidasiguritse kwa muganga Hinjira muri uwo murwi indwara zose z’umubiri ataco ziturutseko kiboneka co mu mubiri. Ivyo gufatirako : Uwo muce uzokoreshwa gusa igihe a) hamaze gukorwa ibipimo bikenewe vy’umubiri, b) igihe umuntu atari mu murwi umwe muri itandatu yavuzwe aho jejuru na c) igihe umuntu asavye ubufasha. Ivyongeweko 1: Uburyo bwo gutanga amakuru y’ubuvuzi (SIS) – Insiguro y’indwara – UNHCR (2014) 1. Intandara/Ibisahuzi Uwakwituye yaragize n’imiburiburi ibiringo bibibri vy’ibisahuzi bitavuye ku kindi gituma kigaragara nk’ubushuye, ubwandu, igikomere canke guhagarika bukwinabukwi inzoga. Ivyo biringo birangwa no gutakaza ubwenge no kujugumira amaguru n’amaboko bikurikirwa rimwe na rimwe n’ibikomere, kwiyononako umwanda mukuru/mutoyi no kwihekenya ururimi. 2. Akaborerwe n’izindi ndwara zifatiye ku gufata ibiyayuramutwe Umuntu arondera kunywa inzoga, canke ibindi bintu bitera ukwizizirwa n’ivyo aba yafashe, kandi akaba afise ingorane zo kwigerera kubifata. Imigenderanire n’abandi, ubushobozi mu kazi n’amagara y’umubiri kenshi biba bigeramiwe. Hampande y’ingorane ziwe umuntu abandanya anywa inzoga, canke ibindi bintu bitera kutihangana. 3. Ubukehabwenge Umuntu afise urugero rw’ubwenge ruri hasi cane rumutera ibibazo mu buzima bwa minsi yose. Mu bwana, yaragize ugucererwa kumenya kuvuga. Akuze, ashobora gukora ibikorwa bibayabaye gusa. Umuntu ashobora gake cane kubaho yigenga canke ngo yiyitwararike wenyene na/canke abo afasha atabufasha ahawe n’abandi. Igihe ubukehabwenge burengeje, arashobora kugira ingorane zo kuvuga no gutahura abandi, kandi ashobora kwama akeneye ubufasha. 4. Indwara zo mu mutwe zeruye (harimwo n’indwara y’umunezero ndenzarugero) Birashika ko umuntu yumva canke abona ibintu bitariho canke akizera ibintu atari vyo. Arashobora kwivugana, akagira imvugo idatahuritka canke itumvikana hamwe n’imero itamenyerewe. Arashobora no kutiyitaho wenyene. Arashobora no kugira ibiringo vy’umunezero ndenzarugero cane canke ishavu riza ningoga, inguvu zirenze urugero, ijwi rirenga n’ukuba ataco yinona. Afatwa nk’umuntu atameze neza « umusazi » n’abandi basangiye imico. Indwara yo mu mutwe yeruye y’umushuhira, indwara yo mu mutwe yeruye imara umwanya munini kandi iguma igaruka, indwara y’umunezero ndenzarugero, hamwe n’ukwemera ntayegayezwa ibintu bitari vyo gutandukanye n’ukw’abandi basangiye imico biri muri uwo murwi. Ivyongeweko 59 Ivyongeweko 2 : Insiguro y’amajambo agoye11 12 Urusina Igwirirana ridasanzwe ry’amazi munda, bishobora kuva ku bituma bitandukanye. Ingaruka mbi z’umuti uvura indwara zo mu mutwe Kwumva udashobora kuguma hamwe bitakuvuyeko, kenshi bikajana n’ukwikomakoma kurengeje kwibonekeza (nk’akarorero ukwiyambagura kw’amaguru, kutagumiza ibirenge hamwe, gushaka kuguma azunguruka, kudashobora kuguma yicaye canke kuguma hamwe). Imiti yitwa « Amphétamines » Umurwi w’ibiyayura mutwe bikabura ubwonko. Bishobora kuduza ukwiyemera kw’umuntu no kwumva umenga yama ari maso. Bishobora gukoreshwa mu buvuzi bw’indwara zimwe zimwe z’amagara y’abantu mugabo bishobora gukoreshwa nk’ibiyovyabwenge bishobora gutuma ubona canke wumva ivy’abandi batumva canke batabona, ukuyinga n’ingaruka ku mutima no ku mitsi. Gukabura inyifato Ubufasha bw’inyifato burondera kuduza imero mu gutanguza ibikorwa vyihariye vyahora bikundwa, naho mur’uwo mwanya ataba ashwashwanutse. Ubwo bufasha bushobora gukoreshwa bwonyene canke mu gihe c’ubuvuzi bw’ivyiyumviro n’inyifato. Imiti « Benzodiazépines » Umurwi w’imiti ifise ubushobozi bwo gusinziriza, kuvura uruhagarara, ibisahuzi, itanga ukworoherwa mu mubiri. Indwara z’umunezero ndenzarugero n’akabonge Indwara zo mu mutwe zihambaye zirangwa n’ibisikanya ry’ikiringo c’umunezero ndenzarugero n’akabonge. Igabanuka ry’uturema ngingo tw’umusokoro Indwara y’umusokoro, ishobora gutuma igabanuka ry’ihingurwa ry’amaraso. Ikiyayura mutwe « Cannabis » Ni kamwe mu duce tugize urumogi, hakurwamwo « marijuana », «haschich (hashishi) » na « amavuta ya cannabis (kanabisi) ». Ivyo bintu barabitumura canke bakabimira kugira bitange umunezero, ukworoherwa mu mubiri n’ihinduka ryo kubona no kwumva ibidukikije. Birashobora kugabanya ububabare. Mu ngaruka mbi harimwo ukudendebukirwa, kwiyambagura n’umwikeko urenze urugero. Indwara yo kumugara kw’ubwonko Igabanuka ry’ubushobozi bw’umubiri n’ubwenge biterwa n’ukwononekara gutangura kare kandi kwamaho kujanye n’ikura ry’ubwonko. Ubwenge Ugukora kw’umutwe kujanye n’ivyiyumviro. Harimwo ukwiyumvira, ukwibuka, kuzirikana, gutora inyishu y’ingorane no gutegekanya. Ubufasha bw’ubwenge n’inyifato Ubufasha bw’inyifato bufatanya ibigize ubwenge (bifise intumbero yo kwiyumvira ibitandukanye, nk’akarorero mu kurondera no kunebagura ivyiyumviro bibi bitari vyo) hamwe n’ibigize inyifato (bifise intumbero yo gukora ibintu ugutandukanye, nk’akarorero mu gufasha umuntu gutangura ibikorwa vyihariye bimunezera). Ubufasha bw’ubwenge n’inyifato bw’inyuma y’ihahamuka Ubufasha bw’inyifato bufatiye kuciyumviro c’uko abantu bafise ihahamuka bagira ivyiyumviro n’ivyo bemera ataco bifasha kuvyerekeye igihe nsesereza mutima hamwe n’inkurikizi zaco. Ivyo vyiyumviro n’ivyo yemera bituma ukwirinda bitagira ikimazi ico cose kimwibutsa ico gihe kandi bigakomeza ibigumbagumba vy’icago kigumaho. Muri rusangi, ubufasha bujanye n’ugusubiza umuntu aho hantu yagiriye ingorane hamwe n’ukudaha agaciro ivyiyumviro n’ivyo yemera bitarivyo ku bijanye n’ugusesererwa. Ukumenyereza gufatiye ku kibano Umurwi w’ubutabazi bwashizweho mu rwego rw’ikibano biciye mu buhinga butandukanye, hakoreshejwe ibigo n’uburyo bwo mu kibano busanzwe buhari. Ubwo butabazi bufise intumbero yo gufasha ukumenyereza mu guteza imbere imibereho myiza y’abantu bagendana ubumuga n’imiryango yabo, mu gufasha ivyankenerwa vy’ibanze no mu gufasha kubasubiza mu kibano no kubigiramwo uruhara. Kwemera kutayegayezwa kw’ibintu atari vyo Imero yo mu mutwe ihindagurika kandi itamara umwanya munini irangwa n’ihungabana ryo kugaba (nk’ukugabanuka kw’ubushobozi bwo kwerekeza, gutumbereza, kugumiza no kugarukana ukugaba kwiwe) n’iryo gukoresha ubwenge (nk’igabanuka ry’ukubona ibimukikije), bishika mu mwanya mutoyi kandi bikamera nk’ibihindagurika ku munsi. Iyo mero ijana n’ibindi bihungabana bijanye n’ukwumva canke ukubona, ukwibuka, ukwiyumvira, ibishobisho canke ibikorwa bijanye n’inyifato. Bishobora kuva ku bituma bukwinabukwi vy’umubiri nk’ubwandu, imiti yo kwa muganga, ihungabana ry’uko umubiri uhingura ibifungurwa, gufata ibiyayura mutwe canke kubihagarika. Ukubona ikintu ukutariko Ukwemera kutayegayezwa gutandukanye n’ivyemezo bihari. Ntigushobora guhindurwa n’insiguro y’ukuri kandi ntikwemerwa n’abo basangiye imico n’uwo muntu (n’ukuvuga ko kutavuye ku kwemera kw’idini). Kwizirirwa n’ivyo bafata Abantu baba biziziwe n’ico bafata (ibiyayuramutwe, inzoga canke itabi) iyo bagaragaje ibimenyetso vy’ubwenge, inyifato, uko umubiri ukora bitameze neza mu gihe habuze ico kintu. Ivyo bimenyetso vyo kukibura bibatuma gusubira kugifata. Ntibashobora kugenzura uko babifata kandi barabibandanya naho bifise ingaruka mbi. Imbonero z’ijisho zagutse/zigabanutse Imbonero (agahimba kirabura k’ijisho) n’iyinjiriro riri hagati y’agahimba bita « iris » itunganya urugero rw’umuco winjira mu jisho. Mu bisanzwe imbonero zirituna ku zuba kugira zikingire ijisho hama zikavyimba mu mwijima kugira hinjire umuco ushoboka. Kugira imbonero zivyimvye canke zitunye bishobora kuba ikimenyetso cerekana ko umuntu yafashe ibiyayuramutwe. 10 Amajambo ya kazinduzi yerekanwa n’akanyenyeri*mu gisomwa. 11 Insiguro zikoreshwa zatanzwe muri iyi kazinduzi zagenewe gusa gukoreshwa mu ntumbero no mu bihe bijanye n’igitabu c’ubutabazi bw’abantu « mhGAP (GIH- mhGAP) » : Ukuvura indwara zo mu mutwe, z’udutsi nsozabwenge n’izijanye no gufata ibiyayuramutwe mu bihe vy’ivyago « (OMS et UNHCR, 2015) ». 60 Akaronda gaterwa n’ukuboneka kw’agace k’akaremangingo 21 (trisomie 21) Akaronda gaterwa n’ukuboneka kw’agace k’akaremangingo 21 karengako.Iherekezwa n’ingero zitandukanye z’ubukehabwenge, ukuzingama n’ibimenyetso vyibonekeza vyo mu maso. Indwara iterwa n’umuti uba watanze mu kuvura iyindi ndwara N’igihe umuti wanditswe mu kuvura indwara uca utera iyindi ndwara kur’uyo muntu nyene. Ugukorana kw’imiti N’igihe imiti ibiri ikoreshejwe k’umuntu umwe ikorana hagati yayo hanyuma igahundura ugukora kw’umwe canke kw’iyo miti ibiri. Ukwo gukorana kurashobora kugabanya, kwongereza canke kunyarutsa ikora ry’umuti canke hakaba inkurikizi mbi. Ingorane z’ikora ry’umubiri bivuye ku miti Ingorane z’ikora ry’umubiri, kenshi ziterwa n’imiti y’indwara zo mu mutwe zeruye. Bishobora kuba igicuro, kudadarara canke kujugumira kw’umubiri na/ canke kutaguma hamwe. Ubufasha bw’inyifato bufatiye ku ciyumviro, ukoresheje uguhindukiza amaso uva iburyo uja i bubamfu Ubufasha bw’inyifato bufatiye ku ciyumviro c’uko ivyiyumviro, ibigumbagumba n’inyifato bibi biterwa n’ivyo yibuka atashoboye kwakira vy’ibihe nseserezamutima. Ubufasha bukoresha inzira zikoreshwa hose, zituma cane cane haba gufatira icarimwe ku (a) guhuza amasanamu, ivyiyumviro, ibishobisho, n’ukwumva ibimenyetso vy’umubiri bisesereza, na (b) gukabura impande zibiri z’amaso, muri rusangi nk’aho ari gutembereza amaso vyisubiriza. Igarukagaruka Ikiringo umuntu yiyumvira akongera akifata igihe kimwe kimwe nk’uko yoba yasubiye muri ca gihe c’icago, akakibamwo bushasha. Abantu bagira igarukagaruka ry’ibihe babayemwo baratakaza ukuri kw’ivyo babayemwo, muri rusangi mu kiringo c’ imisogonda canke iminota mikeyi. Kubona canke kwumva ibintu bitahari Kubona, kwumva, kumoterwa canke kwumva akanovera k’ibintu bitahari. Ihungabana ry’ikora ry’ubwonko bivuye ku gitigu Imero yo mu mutwe itameze neza (irimwo kwisinzirirako, gucanganyikirwa canke gutakaza ubwenge) biterwa no gukora nabi kw’igitigu. Ihungabana rituma agahimba tiroyide (thyroïde) gakora cane N’indwara ituma hakorwa hakongera hagasohorwa ku bwinshi inkabuzo z’agahimba tiroyide « hormones thyroïdiennes » Bimwe mu bimenyetso vy’iyo ndwara, nko kwemeza ibintu atari vyo, kujugumira, ivumbuka ry’umurindi w’amaraso n’ukwiruka kw’umutima, bishobora kwitiranwa no guhagarika inzoga bukwinabukwi. Guhezagirika Guhema nabi kunyaruka, bitera igabanuka ry’umwuka mubi mu maraso. (CO2) Iryo gabanuka rishobora gutera ibimenyetso vyerekana utuntu dutondera canke tuzibagura kumpera z’intoke, hirya no hino k’umunwa, ububabare mugikiriza n’ibizunguzungu. Igabanuka ry’isukari mu maraso Igabanuka ridasanzwe ry’isukari mu maraso. Igabanuka ry’umunyu Igabanuka ridasanzwe ry’umunyu mu maraso. Ihungabana rituma agahimba tiroyide (thyroïde) gakora bukebuke Igabanuka ryo gukora ry’agahimba « thyroïde ». K’uwukuze, ishobora kwerekanwa n’ibimenyetso bitandukanye nk’uburuhe, kumera nk’uwatakaje ubwenge, kuduga ibiro n’ivyiyumviro bibi, bishobora gusa n’akabonge. Igihe ivukanwe kandi ntivurwe ishobora gutera ubukehabwenge no kuzingama. Ubufasha bufatiye ku migenderanire n’abantu Ubufasha bw’inyifato bwerekeje kw’isano riri hagati y’ibimenyetso vyo kuyinga n’ingorane ziri hagati y’abantu, cane cane izitewe n’ukubura, amatati, ukwigunga n’impinduka zikomeye z’ubuzima. Ivyiyumviro vyiyadukiza Ivyiyumviro vyisubiriza, vyiyadukiza kandi bibabaza vyo mu gihe nseserezamutima. Ikena ry’icunyunyu iode Imero ishika mu gihe umubiri uba udafise icunyunyu gikwiye ca «Iode » kugira ikore nkuko bitunganije inkabuzo mu gace kitwa «thyroïde », bikagira inkurikizi mu gukura no gukomera.  Ikiyayuramutwe « Khat » Amababi y’igiti bita « Catha edulis », arimwo ikintu gikabura. N’ikiyayuramutwe kinezereza kandi gifise ingaruka mbi gishobora gutera kudashobora kucihanganira. Guhindukiza umuntu icarimwe Uburyo bw’uguhindukiza umuntu uva ku rubavu uja kurundi utamugonze izosi n’umugongo, kugira wirinde iyononekara ry’umusokoro w’uruti rw’umugongo. Imugara ridatahuritse kwa muganga Gutakaza burundu canke vy’imfatakibanza kw’inguvu muri kimwe mu bihimba vy’umubiri atacabiteye na kimwe co mu mubiri cigeze kiboneka. Ubwandu bwo mubwonko Iyononekara ry’uduhimba dufutse ubwonko hamwe n’umusokoro w’uruti rw’umugongo muri rusangi bitewe n’ubwandu. Ihungabana ry’ingene umubiri uhingura ivy’ukeneye Ihungabana ry’inkabuzo, ivyunyunyu canke vitamine vy’umubiri. Ikigandaro Uburyo umuntu yabuze uwiwe akoresha mu gusezera no kwibuka uwitavye Imana, ari wenyene canke mubandi. Ikigandaro gituma muri rusangi haba imigirwa (nko guhamba) n’inyifato kama (nko guhindura impuzu, muhira canke kwisonzesha). Ubwandu bw’ubwonko Ubwandu bufatira mu bwonko na/canke umusokoro w’uruti rw’umugongo. Ingaruka mbi zikomeye z’imiti ivura indwara zo mu mutwe zeruye N’indwara iboneka gake ariko ishobora guhitana ubuzima bw’umuntu, iterwa n’imiti y’indwara zo mu mutwe zeruye hama ikarangwa n’ubushuhe, ukwemera kutayegayezwa kw’ibintu bitarivyo, ukudadarara kw’umubiri n’ivumbuka ry’umurindi w’amaraso. Imiti Anti-inflammatoires non stéroïdiens (AINS) Umurwi w’imiti ikoreshwa mu kuvura ubuvyimbe burimwo ubushuhe n’ububabare. Ikoreshwa kenshi mu kugabanya ububabare (nk’akarorero « ‘ibuprofène ». Ikiyayuramutwe « Opiacé » Ikiyayuramutwe kiva mu giterwa « pavot à opium ». Ivyo biyayuramutwe ni imiti y’ububabare ifise akamaro kanini ariko ishobora gutera ikibazo co kuyihagarika. Héroïne iri muri uwo murwi. 61 Ikoroka ry’umurindi w’amaraso iyo uhagurutse bukwinabukwi wari uryamye canke wicaye Ukugabanuka bukwinabukwi kw’umurindi w’amaraso gushobora kuba mu gihe uhagurutse bukwinabukwi wari uryamye canke wicaye, muri rusangi bitera kwumva umemga urataye ubwenge canke ibizunguzungu. Nta ngorane bitera ku magara y’umuntu. Kuvuza imiti myinshi Ubuvuzi bufatiye ku miti myinshi itandukanye ku ndwara imwe. Igihe gishobora kuba nseserezamutima Igihe cose giteye ubwoba canke gikomeye, nk’ikubagurwa ryo ku mubiri canke rifatiye ku gitsina, kubona ibintu biteye ubwoba, gusamburirwa inzu canke amasanganya canke ibikomere bikomeye. Ivyo bihe bizohahamura umuntu canke ntibibe bivanye n’ukuntu yavyakiriye. Ubuhanuzi bufatiye ku gutora inyishu z’ingorane Ubufasha bw’inyifato butuma ikoreshwa ritunganijwe ry’ubuhinga bwo gutohoza no gutorera inyishu ibibazo biciye ku masango menshi. Ubuhinga bwo gutora inyishu z’ingorane Ubuhinga bwo gukorana n’umuntu mu gutora inyishu n’uburyo bwo gutorera umuti ingorane zabonetse, kuzitondeka uhereye kuzihutirwa hamwe no kuvugana uburyo bwo kubishira mu ngiro. Mu gitabo « mhGAP », ijambo « counselling » mu gutora inyishu z’ibibazo»rikoreshwa mu gihe uburyo bwakoreshejwe butunganijwe ku masango menshi. Ibisahuzi bidafashe Ikiringo gisa n’indwara y’intandara ariko atariyo. Ivyo bihe bishobora gusa n’indwara y’intandara ufatiye ku gutakaza ubwenge no kujugumira ariko kwihekenya ururimi, inguma zikomeye zivuye ku kurwa bukumbi no kwigirako umwanda muto/mukuru biboneka gake. Ivyo bihe ntivyerekana ikimenyetso kimwe c’umuyagankuba wo mu bwonko nk’indwara y’intandara. Ibimenyetso ntibiba vyavuye ku ndwara y’udutsi nsozabwenge, ku biyayuramutwe canke ku muti. Mu bitegekanijwe na « CIM-11 », ivyo bihe vyafashwe nk’indwara iyo umuntu adatahura inyifato y’ibihimba vyiwe. Ubutabazi bwa mbere bw’inyifato Ubufasha bwa mbere buhabwa abantu bari mu gahinda bahejeje guhura n’ikiza : ugusuzuma imyitwarariko n’ivyankenerwa vyihuta, ubufasha bw’ibanze bwo ku mubiri bwihuta, kuzana canke guhimiriza ubufasha mu kibano, gukinga ikiza cose gishasha. Inyifato isubiza inyuma Inyifato itabereye mu gihe co gukura kw’umwana ariko ihuriranye n’iy’umwana muto cane. Kwigirako umwanda muto n’inyifato yo kwikwegerako n’uburorero bukunze kuboneka. Igabanuka rikomeye ryo guhema Ni uburyo bwo guhema bwikwega cane, butuma igabanuka ry’impwemu nziza.Udukomere tw’ubwonko n’ingaruka mbi zivyo uba wariye canke wanyoye (nk’akarorero bitewe n’imiti bita benzodiazépines) biri mu bituma bikunze kuboneka. Ibisahuzi Ikiringo c’ikora nabi ry’ubwonko rivuye kw’irengana ritameze neza ry’umuyaga nkuba mudutsi tw’ubwonko. Inyifato yo kwigirira nabi Kwiha ishano canke ukwikomeretsa umuntu yigirira abishaka, intumbero canke inkurikizi yavyo ishobora kuba ugupfa canke ukudapfa. Ukwivura Inzoga, ibiyayuramutwe canke imiti (harimwo niyanditswe na muganga) abantu biha bonyene kugira bagabanye ingorane z’umubiri canke z’inyifato batabonanye n’umuvuzi. Indwara y’ubwandu bugeze kure N’indwara ishobora guhitana ubuzima bw’umuntu iterwa n’ubwandu bukomeye, cane cane irangwa n’ubushuhe, ihagarara ry’itembera ry’amaraso n’ugukora nabi kw’ibihimba vy’umubiri. Igabanuka ry’itembera ry’amaraso Igabanuka ry’itembera ry’amaraso ritewe n’ubwandu canke n’ubundi bumara, bimanura cane umurindi w’amaraso k’urugero rwica. Irangwa n’umurindi w’amaraso uri hasi cane canke utumvikana, gukanya ku rukoba, umutima utera buhoro buhoro canke utumvikana, uguhema bigoranye n’ihungabana ry’ubwenge. Imiti « ISRS » Ubwoko bw’imiti y’akabonge, kuyinga ibuza k’uburyo bwiharije kwakira inkaburamubiri yitwa serotonine. Serotonine ni inkaburamubiri yo mu bwonko ihindura imero y’umuntu. Fluoxetine iri muri uwo murwi. Imiti « Stéroïdes » Umurwi w’inkaburamubiri zihari nk’imiti zifise akamaro kanini mu kuzimanganya ibimenyetso birimwo kuvyimba, gushuha, kubabara bivuye ku bwandu, ku bumara no kurindi hungabana ry’abasoda b’umubiri. Imiti yitwa glucocorticoïdes (nk’akarorero prednisolone) hamwe n’imiti yo gutandukanya imvyaro ifatiye ku nkaburamubiri ni bumwe mu burorero bwama stéroïdes. Indwara « Syndrome de Stevens Johnson » Indwara yo ku rukora irangwa no gushishagurika kubabaza, kumyoka, ibibubi n’ukwunuka nko mu kanwa, ku minwa, mu muhogo, ku rurimi, mu maso no mu bihimba vy’irondoka, rimwe na rimwe bijana n’ubushuhe. Iiterwa kenshi n’ingaruka zikomeye z’imiti cane cane irwanya intandara. Kwiyahura Ukwiyaka ubuzima n’ibigira nkana. Imiti ATC Ubwoko bw’imiti y’akabonge, kuyinga ibuza k’uburyo bwiharije kwakira inkaburamubiri zitwa noradrenaline na serotonine. Amitriptyline na clomipramine ni uburorero. Gukenerwa kw’ingero ziyongerako kugira uronke umunezero ungana n’uwo wahora uronka ufashe urugero rw’ibiyayuramutwe rwari rumenyerewe gufatwa Igabanuka ry’ikora ry’ikiyayuramutwe cafashwe k’urugero rumwe. Bitumwa n’uko umubiri wamenyereye kuronka ico kiyayuramutwe bivanye no kugifata umwanya munini. Harakenerwa ingero ziyongerako kugira uwubifata amererwe nk’uko yahora amererwa. Ukwunuka kw’umubiri Ukwunuka kw’umubiri gushobora guhitana ubuzima bw’umuntu kuva ku muti canke k’ubwandu. Bifitaniye isano na « syndrome de Stevens-Johnson » yamara kurahambaye cane gose. Umuti Tramadol Ni umuti bandika kugira ugabanye ububabare.Rimwe na rimwe ukoreshejwe uko bidategekanijwe ushobora gutanga ibimenyetso vy’umunezero ndenzarugero (kumva umenga « woyamira » canke umunezero mwinshi cane). Kujugumira Kujugumira canke gusahagurika kw’intoke muri rusangi. Ubwandu bw’uruhago (urosepsis) Ni indwara iterwa n’ubwandu bukomeye bwo mu ruhago. 62 Ivyongeweko 3. Urutonde rw’ibimenyetso vy’indwara Uguhagarika umutima Uruhagarara rw’umushuhira rwo mu mutima (STR) Indwara yo kuyinga n’akabonge (DEP) Ihahamuka (ESPT) Indwara yo mu mutwe yeruye (PSY) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) Ingorane z’akayabagu Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Kwigirako umwanda muto Uruhagarara rw’umushuhira rwo mu mutima (STR) Ubukehabwenge (DI) Gucanganikirwa Indwara yo mu mutwe yeruye (PSY) Intandara/ ibisahuzi (EPI) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) Kubona ikintu ukutari kwo Indwara yo mu mutwe yeruye (PSY) Ingorane zo gukora ibikorwa bimenyerewe Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Ihahamuka (ESPT) Indwara yo mu mutwe yeruye (PSY) Ubukehabwenge (DI) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) Igarukagaruka Uruhagarara rw’umushuhira rwo mu mutima (STR) Ihahamuka (ESPT) Kwumva canke kubona ibintu abandi batabona Indwara yo mu mutwe yeruye (PSY) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) Umwiheburo Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Kwiyahura (SUI) Guhezagirika Uruhagarara rw’umushuhira rwo mu mutima (STR) Kwiyononako Intandara/ ibisahuzi (EPI) Ubukehabwenge (DI) Kubura itiro Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Ingwara yo kuyinga n’akabonge (DEP) Ihahamuka (ESPT) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) Ivyiyumviro vyiyadukiza Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Ihahamuka (ESPT) Gushavuzwa n’ubusa Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Ihahamuka (ESPT) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) 63 Ingorane zo kwiga Ubukehabwenge (DI) Gucika intege Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Kutagira ikikuryohera n’ikiguhimbara Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Kutiyitaho bikwiye Indwara yo mu mutwe yeruye (PSY) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) Kudendebukirwa Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Ihahamuka (ESPT) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) Umubabaro Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Ibisahuzi Intandara/ ibisahuzi (EPI) Gufata inzoga n’ibiyayuramutwe ku rugero ruhungabanya amagara (SUB) Inyifato yo kwigirira nabi Kwiyahura (SUI) Kwigunga Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Indwara yo mu mutwe yeruye (PSY) Ibimenyetso vyo mu mubiri bidasiguritse Uruhagarara rw’umushuhira rwo mu mutima (STR) Ikigandaro (DEU) Indwara yo kuyinga n’akabonge (DEP) Ihahamuka (ESPT) Indinganizo y’igikorwa co gukuraho agahaze ku magara yo mu mutwe (mhGAP) © Stichting Kennis zonder Grenzen 2021 www.kenniszondergrenzen.nl www.samandari.org Muri buri kigo c’amagara muri rusangi mu gihe c’ubutabazi, n’imiburiburi umwe mu bavuzi mubigishijwe yategerezwa kumenya gusuzuma no kuvura indwara zo mu mutwe, z’imitsi nsozabwenge n’izifatiye ku kunywa inzoga no gufata ibiyayuramutwe. Igitabo c’ubutabazi bw’abantu mhGAP(GIH-mhGAP) ni isoko ryoroshe kandi rikoreshwa mu gushika kw’iryo hangiro.