Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders
Mental, neurological and substance use (MNS) disorders are major contributors to morbidity and premature mortality in all regions of the world. Nevertheless, WHO estimates that over 75% of people with MNS disorders are unable to access the treatment or care they need.
The mhGAP guideline supports countries to strengthen capacity to deal with the growing burden of these conditions and narrow the treatment gap. It is intended for use by doctors, nurses, other healthcare practitioners working in non-specialist settings at primary health care level, as well as health planners and managers.
The 2023 guideline update includes 30 updated and 18 new recommendations related to MNS conditions, alongside 90 pre-existing recommendations.
This is the third iteration of the guideline and reflects 15 years of investment in the mhGAP programme. The revised recommendations ensure that mhGAP continues to offer high-quality, timely, transparent, and evidence-based guidance to support non-specialist health workers in low-income and middle-income countries in providing treatment and care to individuals with MNS conditions.
For 15 years, mhGAP has played a vital role in improving access to evidence-based psychological interventions and medicines for the treatment and care of people with mental, neurological and substance use disorders,” said Dévora Kestel, WHO Director for Mental Health and Substance Use, as per WHO press release.
Considering the growing relevance of mental health, this evidence-based guide is more important than ever in supporting primary health care workers to treat people with MNS disorders.”
Dévora Kestel, Director for Mental Health and Substance Use, World Health Organization
How the new and updated guide addresses alcohol
Alcohol, especially alcohol use disorder, is mentioned 74 times throughout the guide. The 2023 guideline includes 48 updated and new evidence-based recommendations related to MNS conditions. The updated and new recommendations stand alongside 90 pre-existing guideline recommendations which were validated and continue to be endorsed in their current format.
Concerning alcohol use disorder, there are two updated and two new recommendations.
| Alcohol use disorders (ALC) | |
|---|---|
| Module and recommendation number | Recommendation Strength of the recommendation and certainty of the evidence |
| ALC1 (update) | Baclofen should be considered for treatment of adults with alcohol dependence post-detoxification. Conditional recommendation. Moderate certainty of evidence. |
| ALC2 (update) | Structured and standardized psychosocial interventions should be considered for the treatment of alcohol dependence. Conditional recommendation. Low certainty of evidence. |
| ALC3 (new) | Digitally delivered interventions should be considered for adults with alcohol use disorders or with hazardous alcohol use. They should not replace provision of other forms of interventions and should ensure free and informed consent, safety, confidentiality, privacy and security. Conditional recommendation. Low certainty of evidence. |
| ALC4 (new) | Combined psychosocial and pharmacological interventions should be offered for adults with alcohol dependence. Strong recommendation. Moderate certainty of evidence. |
For each of these four recommendations, the guide provides detailed information on justification, remarks, research gaps, and implementation considerations.
In this way, the guide answers four questions:
- In adults with alcohol dependence post-detoxification is baclofen effective for relapse prevention and management of alcohol dependence?
- In adults with alcohol dependence are psychosocial interventions effective?
- In adults with alcohol use disorders or hazardous alcohol use, are digital interventions effective?
- In adults with alcohol use disorders, are combined pharmacological and psychosocial interventions effective and safe?
This mhGAP guideline aims to facilitate implementation of the Global alcohol action plan 2022–2030 by healthcare planners and programme managers in LMICs.
The guide also briefly addresses alcohol in the areas of other drugs and epilepsy, recommending that people with epilepsy should be encouraged to “avoid excess alcohol consumption and to not take recreational substances.”
What’s missing
The guide fails to address the needs for services and interventions of children and youth affected by alcohol use disorder and addiction either directly or indirectly.
The guide also fails to investigate whether brief psychosocial interventions for people with alcohol use disorder are effective in reducing and/ or quitting alcohol use.
The guide further fails to investigate whether psychosocial interventions are effective in the
treatment of alcohol use disorder among children and youth.
The guide also fails to investigate whether recovery-oriented services for people with alcohol use disorder and addiction, such as mutual aid and self-help groups, are effective.
The guide does not address the mental health needs of people with FASD.
New recommendations on anxiety disorders
The guideline contains a new module on anxiety reflecting the increased number of people with anxiety disorders, which are among the world’s most common mental disorders. The module includes the following recommendations:
- Psychological interventions based on cognitive behavioural therapy (CBT) should be offered to adults with generalized anxiety disorder and/or panic disorder. These interventions can be offered in a variety of formats including online, in-person, in groups, or self-guided.
- Stress management techniques should be considered for adults with generalised anxiety and/or panic disorder.
- Selective Serotonin Reuptake Inhibitors (SSRIs) should be considered for treating adults with generalized anxiety and/or panic disorder.
Psychological and psychosocial interventions
The guideline sets out the continuing importance of psychological treatments for a range of MNS conditions.
The mhGAP guideline contains new recommendations on psychosocial interventions for carers of persons with psychosis or bipolar disorder as well as new recommendations on psychosocial interventions for psychosis, alcohol dependence, substance use, dementia, and children and adolescents with neurodevelopmental disorders including autism, ADHD and cerebral palsy.
Additional information on mhGAP
- First published in 2010 and last updated in 2015, the mhGAP guideline, and its associated products including the mhGAP intervention guide, are now used in more than 100 countries and available in over 20 languages.
- The mhGAP guideline was updated in accordance with the WHO handbook for guideline development and meets international standards for evidence-based guidelines. In collaboration with the Guideline Development Group (GDG), the Topic Expert Groups (TEGs) and the guideline methodologist, the WHO Steering Group identified priority questions and outcomes to determine those that were critical for the update of the mhGAP guideline.
- Systematic evidence reviews were used to develop the Evidence to Decision and Summary of Findings tables, according to the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach.
- The GDG, developed recommendations that considered a range of elements, namely: the certainty of the evidence; the balance between desirable and undesirable effects; values and preferences of intended users of the intervention; resource requirements and cost-effectiveness; health equity, equality and non-discrimination; feasibility; human rights and sociocultural acceptability.
