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Mental Health in Primary Care Diagnostic and Treatment Guidelines

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Mental Health in Primary Care Diagnostic and Treatment Guidelines SULTANATE OF OMAN MINISTRY OF HEALTH MANUAL FOR THE MANAGEMENT OF MENTAL ILLNESS IN PRIMARY HEALTH CARE SECOND EDITION-2011 DEPARTMENT OF NON COMMUNICABLE DISEASES SURVEILLANCE &CONTROL IBN-SINA HOSPITAL DEPARTMENT OF PRIMARY HEALTH CARE. MR - 414 PREFACE Health is “the complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organisation Constitution 1948). Thus mental health is an integral part of health and plays an important role in the overall health of individuals, families, communities and nations. Indeed, there is no health without mental health. It is therefore important to include mental health in preventive, curative and rehabilitative health care services in every stage of development in the human life cycle. Despite there being no doubt that mental health is as important as physical health to overall well being of individuals, societies and countries, only a small minority of the 450 million people in the world suffering from a mental or behavioural disorder are receiving treatment, and this is also true of Oman as well as other countries . Prevention of all illnesses and disabilities is the policy of the Ministry of Health in Sultanate of Oman. There is a need to provide easily accessible, effective and early recognition of mental disabilities because delay produces adverse effects not only on the patients and their families but also on the whole economy and overall well being of society. Early recognition leads to early intervention resulting in better prognosis. Given the prevalence of mental disorders , and the desire to achieve equitable population access to mental health promotion, prevention, and treatment, it is essential , as in other countries, to integrate mental health into primary health care. Therefore this manual forms part of a systematic and comprehensive program to integrate mental health into Oman's primary health care system. As well as this manual, other components of the program include training of primary health care doctors and nurses in mental health, inclusion of mental disorders in the primary care IT system, provision of medicines in primary care, and other supportive issues. Thus it is intended that primary care staff will be empowered with the necessary knowledge, skills, competence and attitude to recognize and manage mental health problems both in the community and Primary Health Care facilities. Advances in neuroscience and behavioural medicine have shown that, like many physical illnesses, mental disorders are the result of complex interaction between biological, psychological and social factors. Therefore the approach taken throughout our programme is a biopsychsocial approach: biopsychosocial assessment and biopsychosocial management. This manual therefore provides a set of standardised methods and guidelines to identify and evaluate psychological disorders in all health care facilities in Oman, especially in primary health care, along side any physical conditions and social issues which the patient may have. The preparation and publication of this manual is the culmination of the efforts of numerous people who are concerned with caring for the mentally ill, in supporting their families and in planning the provision of psychiatric care in Oman. The Ministry of Health would like to thank them for their commendable efforts in producing this manual. The World Health Organization office in Oman has also been closely involved in the publication of this manual and in providing all kinds of assistance, advice and support. Their role is highly appreciated. Dr. Mohammed bin Said bin Sultan Al-Hosani Undersecretary of Health affairs 2 Editor: Dr.Hashim Zainy Specialist psychiatrist In charge of Mental Health Department - non-communicable diseases Surveillance & Control Main contributors 1. Dr. Hashim Zainy Specialist psychiatrist 2. Dr. Nasser Al-Sibani Consultant psychiatrist 3. Dr. Jamila Tufail Al-Rahman Senior specialist psychiatrist 4. Dr. Mahmood Al-Abri Senior specialist psychiatrist Director of Ibn- Sina Mental hospital List of contributors 1- Dr. Sosamma John Consultant psychiatrist 2- Dr.Badrya Al-Rashdi Senior specialist FAMCO 3- Dr.Ahmed Al-Wahaibi Senior specialist FAMCO 4- Dr. Asad Al-Mousawi Senior specialist psychiatrist 5- Dr. Jawad Al- Lawati Director of non-communicable diseases Surveillance & Control 12 - Dr. Said Al- Lamki Director of primary health care department 3 Acknowledgement: The contributors wish to extend their thanks and gratitude to his Excellency the Minister of Health Dr.Ahmed bin Mohammed bin obaid Al-Saidi for his continuous support and encouragement as well as adoption of the program of integrating Mental Health in Primary Health care. Thanks also extended to His Excellency the undersecretary of Health affairs Dr. Mohammed bin Saif bin Sultan Al-Hosani for his help and support. Contributors are also grateful for the continuous support provided by His Excellency Dr. Ali bin Jaffer bin Mohammed, Advisor of health affairs and supervising DGHA Thanks and appreciation offered to Prof. Rachel Jenkins, Consultant psychiatrist, director of WHO Collaborating Centre, Institute of Psychiatry, Kings College London and Dr. Jihane Tawila WR of WHO Oman office for their valuable guidance, suggestions and continuous support. 4 Contents Preface………………………………………………………………………………………………………2 List of contributors………………………………………………………………………………………..3 Acknowledgement………………………………………………………………………………………...4 Introduction……………………………………………………………………………..............7 Section1. General management issues Prevention of mental health problems………………………….……………….….…….11 Management of psychiatric disorders …………………………….……….…….……….12 Assessment of patients in primary health care units………………………….………...12 Roles and responsibilities of health centers……………………………………………...15 Classification of mental disorders………………………………………………………….16 Section 2: Specific mental disorders Depression………………………………..………………………………………………....19 Anxiety…………………………………………………………………………..…………...22 Post traumatic stress disorder……………………………………………………………..28 Somatization disorder……………………...…………………………………….….……...30 Conversion disorder…………………………………………………………………………31 Acute psychosis……………………………….………………………………………….....32 Schizophrenia……………………..................................................................................33 Bipolar affective disorder..……………………………………………………….………….35 Mental and behavioral disorders due to psychoactive substance use…………………37 Dementia……………………………………………………………………………………...48 Mental disorders in women and reproductive psychiatry…………………………..……50 Mental retardation……………………………………………………………………………52 Hyperkinetic disorder………………………………………………………………………...54 Conduct disorder……………………………………………………………………………..55 Childhood emotional disorder……………………………………………………………….56 Reading disorder (Dyslexia)………………………………………………………………...57 Pervasive developmental disorder…………………………………………………………59 5 Section 3: Psychiatric emergencies Managing violent patient …………………………………………….……………………..61 Intentional self harm (suicide)………………………………………..……….…………....65 Main medical/ drug related emergencies in psychiatry…………………………………..69 Section 4: Medication guidelines General principles…………….……………………………………….……………………..76 Antipsychotic medications…………………………………………………………………..77 Antidepressant medications…………………………………………………………………81 Mood stabilizing medications………………………………………………………………..83 Anticholinergic drugs………………………………………………………………………....86 Anxiolytics, sedatives and hypnotics……………………………………………………….87 ANNEXURE 1: Other useful materials Checklists and screening tests for use by professionals in PHC …………………...88 ANNEXURE 2: Medications in PHC Medications approved to use in PHC……………………………………………….………92 Suggested medications for approval to use in PHC………………………………………93 ANNEXURE 3: Glossary of psychiatric signs and Symptoms……………………94 6 Introduction: Global situation: Mental and behavioural disorders are common, affecting more than 25% of all people at some time of their lives. They are also universal affecting people from all countries and societies, individuals at all ages, women and men, the rich and the poor, from urban and rural environments. They have an economic impact on societies and on the quality of life of individuals and families. Mental and behavioural disorders are present at any point in time in about 10% of the adult population. Around 30% of all patients seen by primary health care professionals are diagnosed with mental disorders. One in four families is likely to have at least one member with behavioural or mental disorder. These families not only provide physical and emotional support, but also bear the negative impact of stigma and discrimination. It was estimated that, in 1990, mental and neurological disorders accounted for 10% of the total DALYs lost due to all disease and injuries. This was 12% in 2000.By 2020; it is projected that the burden of these disorders will have increased to 15%. Situation in Oman: An epidemiological survey of school children has been conducted in 2006 showing prevalence rates of mental disorders is 16% which is similar to elsewhere in the world. A similar study on adults has not yet been conducted. As yet there are no prevalence studies of mental disorders in primary care, but international WHO studies have indicated that around 1 in 3 primary care attendees have a psychological disorder. In Oman, until now, the majority of people with identified mental disorders are initially treated by specialist services, and some are followed up by primary care. Specialist services
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