PRACTICAL GUIDELINES

FOR TREATING MENTAL DISORDERS

IN KENYAN GENERAL MEDICAL FACILITIES

SUMMARY:

1) MOOD DISORDERS:a) Major Depressive Disorder: Amitriptilyne (Fluoxetine)b) Bipolar Disorder: Carbamazepine (Haloperidol)

2) ANXIETY DISORDERS:

a) Generalized Anxiety Disorder: Amitriptilyne, (alprazolam)b) Panic Disorder: Amitriptilyne (alprazolam)c) Post traumatic Stress Disorder: fluoxetine (amitriptilyne)d) Obsessive Compulsive Disorder: Amitriptilyne (fluoxetine)e) Prompt control of severe anxiety symptoms or epileptic seizures: diazepam

3) PSYCHOSOMATIC DISORDERS: a) Migraine: prophilaxys with amitriptilyne (propanolol) / Acute treatment: Rizatriptan, Pain Killersb)Tension-Type Headache: prophilaxys with amitriptilyne (propanolol)c) Pain disorder (gastric, back, arm pain etc..): amitriptyline

4) INSOMNIA: Zolpidem (Alprazolam) or Diazepam

5) SUBSTANCE ABUSE AND DEPENDENCE DISORDERS

6) SCHIZOPHRENIA: Haloperidol (Clorpromazine)

NB: Refer all patients for counseling after done a diagnose of any Mental disorder (soft Schizophrenia and Bipolar disorder in acute psychotic phase and patients with very low insight).

Send them to the reception of Ruaraka UIhai Neema Hospital to arrange an appointement (on Tuesday or Thurday)

- If counseling would be not available in our hospital refer patients, with a letter in which you specify the diagnose, to Keniatta National Hospital: Patients Support Centre, near Orthopedyc clinic n.5 , tel 02726300 , email: pscentre14@yahoo.com (300 Sh for the file/ 350 Sh for 1 hour counseling )

- If patient needs Psychiatric counsultation: Refer to Mathari Hospital outpatients clinic (50 Sh for the visit)

- If Children with Mental problems: Refer to Mathari Hospital for Children Psychiatric Assessment and counseling (Only on Wednesday: 50 Sh)

ALGHORITM for INTEGRATING BASIC PSYCHIATRIC CARE AT NEEMA HOSPITAL

- Patient at Triage: Screening for Major Depressive Episode (MDE): No MDE STOP

Risk MDE: Doctor checks if criteria for MDE are present (with MINI-plus): No criteria STOP

Yes criteria MDE and you exclude a past hypomani/manic episode (with MINI-plus):

Diagnose of MAJOR DEPRESSIVE DISORDER (MDD)

Refer for COUNSELING always (appointement at the reception) FARMACOLOGIC TREATMENT if there is the need (see these guidelines)

For other most common diseases (Pain Disorder, Bipolar Disorder, Generalized Anxiety Disorder, Panic Disorder, Post Traumatic Stress disorder) repeat the same alghoritm, but without the screening at triage.

Please, if you have not time to do a psychiatric diagnose but it seem you that the patient had a risk for some mental disorder refer him to counseling for a more comprehensive assessment, specifying the diagnose that you suspect.

During the past two weeks, have you been consistently depressed, down, or less interested in most things, most of the day, nearly every day?

1) MOOD DISORDERS

1A) MAJOR DEPRESSIVE DISORDER (only Major Depressive Episodes, at least one)

a) Preliminary Assessment:- Exclude organic illness (Hypothyroidism, diabetes, cancer, neurological disease)- Exclude Substance abuse disorder- Medical and psychiatric history- Physical and neurologic examination- Mental status assessment- Diagnose

b) 1st steps:- Information- Empathetic listening- Reassurance- Psychological support (e.g. problem solving counselling) - referral to relevant social services and resources in the community.

c) When To use Antidepressants? (if not only counseling)

- Moderate to severe Major depressive Episode- Functional impairment- Long duration of illness (+ 2months)/ Remittent course- Severe somatic complains / concomitant chronic ilness- Alcol or substance abuse- Familiarity for mood disorders- Psychotic symptoms

d) Amitriptyline 25-50 mg nocte

Fluoxetine 20 mg OD

If ContraindicationNot tollerate side effects

Ask for suicidality!!!

+ Counseling

Contraindication: : Pregnancy and breast feeding, Glaucome, hyperthyroidism, prostatic hypertrophy, Stenosis pillorica, heart failure, serious rhythm disturbances, Hypotension,treatment with thyroid ormons, liver diseases, Dementia.

Common adverse effects: dry mouth, constipation, urinary retention, blurred vision and disturbances in accommodation, increased intra-ocular pressure, hyperthermia, drowsiness and increased appetite with weight gain, orthostatic hypotension, tachycardia, sexual dysfunction.

Serious adverse effects: electrocardiogram changes, confusion or delirium, hyponatraemia associated with inappropriate secretion of antidiuretic hormone, peripheral neuropathy, tremor, ataxia, dysarthria, convulsions.

Severity of Major Depressive Episode:

Contraindication: Pregnancy and breast feeding, Hypersensibility

Common adverse effects: gastrointestinal disturbances such as nausea, vomiting, dyspepsia, constipation, diarrhoea, anorexia, weight loss, anxiety, restlessness, nervousness, insomnia; headache, tremor, dizziness, agitation, sexual dysfunction

Serious adverse effects: convulsions, hallucinations, extrapyramidal effects, depersonalisation, panic attacks, hyponatraemia associated with inappropriate secretion of antidiuretic hormone, bleeding disorders, electrocardiogram changes.

Important!!

- Less dosage in elders- Inform patients about side effect and that the benefits of the theraphy will started after 3-4 weeks.- Inform the patients that is a long term theraphy. Not interrupt it when they will feel better because there is a high risk of relaps.

1B) BIPOLAR DISORDER (MDE current or past + Hypomanic episode current or past or at least one Manic Episode)

I) DEPRESSIVE EPISODE and Long Term Treatment

Controindication: serious liver, kidney, heart disease, history of aplasia, pregnancy.

Common adverse effects: dizziness, drowsiness, ataxia, visual disturbances, confusion, agitation, nausea, vomiting, constipation, leukopenia and other blood disorders, erythematous rash, cholestatic jaundice, hepatitis.

Serious adverse effects: Stevens-Johnson syndrome, toxic epidermal necrolysis, hyponatraemia, agranulocytosis, cardiac conduction disturbances, renal failure.

symptoms of carbamazepine overdose: include somnolence, tachycardia, atrioventricular conduction defects, seizures, coma, nystagmus, hyporeflexia or hyperreflexia, rigidity, orofacial dyskinesia, and mild respiratory depression.

NB:

Before and during carbamazepine therapy, monitoring:- Full blood count- Liver and renal function tests- Pregnancy test.If not feasible - Regularly medical examination- Neurologic examination

- Recent medical history that may help recognize symptoms suggesting the development of blood or renal or hepatic abnormalities.

II) HYPOMANIC EPISODE:

ACUTE TREATMENT: Haloperidol 5-10 mg nocte PO + Carbamazepine 200 mg nocte (see 1b.I)

LONG TERM TREATMENT: Continue only with Carbamazepine (see 1b.I)

III) MANIC EPISODE:

ACUTE TREATMENT: Haloperidol 10 mg IM or Chlorpromazine: 150-200 mg IM

POST-ACUTE TREATMENT: Haloperidol 5-10 mg Nocte PO + Carbamazepine (see 1b.I)

LONG TERM: Carbamazepine (see 1b.I); if not enough add Haloperidol 5-10 mg Nocte PO

NB: If Haloperidol is not avaible use Chlorpromazine 100 mg Nocte

If Problems or the patient is not recovering refer to Psychiatrist.

Resolution of Hypomanic Episode

Untill patient can not be managed PO

Resolution of Manic Episode

2) ANXIETY DISORDERS

2A) GENERALIZED ANXIETY DISORDER:

I) Empathic listening, reassurance and guidanceII) Counseling (cognitive-behavioural Psychoterapy) + Relaxation Techniques

III) Short term theraphy:

-Only if patients suffer to much that cannot do counseling without. The objective may be to reduce symptoms enough to allow the patient to engage in treatments based on cognitive-behavioural techniques.Lowest effective dose for as short a period as possible (maximum 3-4 weeks). Then decrease gradually.

Alprazolam: 0,25 mg BD/TDS (up to 1-2 mg BD/TDS) less dependance an sedation than Diazepamor

Diazepam: 2 mg BD/TDS, up to 5 TDS or 10 mg BD.

IV) Long Term theraphy:

- If the disorders is severe, disabling and causing extreme distress, or that have somatic symptoms orthat not responding to psychotherapy, or there is no possibility of Psychotherapy.

Amitriptyline (or fluoxetine) as in Depression (see 1d)

2B) PANIC DISORDER:

Same therapy than Generalized Anxiety Disorder (See 2a-I/III), but, if you need to use Benzodiazepine try first to istruct the patients to use the medicines only when the panic attac will come (or it’s almost to come):

- Alprazolam: 0,5 mg or - Diazepam 5mg

2C) POST TRAUMATIC STRESS DISORDER:

Same therapy than Generalized Anxiety disorder (See 2a-I/III ), but if patients can afford Fluoxetine is the better choice.

If the disturb follow a recent trauma (ACUTE STRESS DISORDER), and the disorders is severe, disabling and causing extreme distress, start with an antidepressant + benzodiazepine.

2D) OBSESSIVE COMPULSIVE DISORDER

I) Gold Standard: Cognitive-behavioural therapy (CBT)II) If it’s no possibile CBT: Amytriptiline or Fluoxetine at high dosages.

IIa) Amitriptyline at high dosage: 75 mg nocte:

After 2 weeks monitoring acute effects

After 3 Months: Evaluation of treatment response (follow alghoritm for depression: see 1d)

IIb) Fluoxetine at high dosage: 40-60 mg nocte:

After 2 weeks monitoring acute effects

After 3 Months: Evaluation of treatment response (follow alghoritm for depression: see 1d)

2E) PROMPT CONTROL OF SEVERE ANXIETY SYMPTOMS:- Diazepam 2-10 mg intramuscular or intravenous injection (repeated after 3-4 hours if needed)

NB: If Anxiety Disorder are associated with depression or with somatic syntoms use immediatly Amitriptyline.Low dosage of Benzodiazepines are request in Children and Elder

1st week: start with 50 mg 2nd week + 25 mg

1st week: start with 20 mg 2nd week + 20 mg

Contraindications of Benzodiazepines:

DIAZEPAM: Pregnancy and Breast feeding, Miastenia gravis, respiratory insufficiency ALPRAZOLAM, ZOLPIDEM: Pregnancy and Breast feeding

Common adverse effects of Diazepam: drowsiness, sedation, muscle weakness. Diazepam can adversely affect parameters of driving performance in healthy subjects.

Serious adverse effects of Diazepam: vertigo, headache, confusion, depression, dysarthria, changes in libido, tremor, visual disturbances, urinary retention or incontinence, gastrointestinal disturbances, changes in salivation, and amnesia. Some patients may experience a paradoxical excitation which may lead to hostility, aggression, and disinhibition. Jaundice, blood disorders, and hypersensitivity reactions have been reported rarely. Respiratory depression and hypotension occasionally occur with high dosage and parenteral administration.

3) PSYCHOSOMATIC DISORDERS

3A) MIGRAINE

How to recognize Migraine?

- Last 4-72h- Pounding unilateral headache- Preceded by visual or other aura- Nausea or vomiting- Light and sound sensitivity

I) ACUTE TREATMENT:

1ST STEP: Oral Analgesics ± Antiemetic

Paracetamol 1g BD/TDS Metoclopramide 10 mg PO or

Ibuprofen 400 mg q3-4h or Naproxen 220-550 mg BD

2ND STEP: Parenteral Analgesics ± Parenteral Antiemetic

Diclofenac IM 75 mg (3ml) Metoclopramide 10 mg (3ml) IM

3RD STEP: Rizatriptan 5-10 mg PO at onset, may repeat after 2h (max 30 mg/d)

Contraindication Rizatriptan: ischemic heart disease (e.g., angina pectoris, history of myocardial infarction, or documented silent ischemia) or other significant underlying cardiovascular disease, uncontrolled hypertension, hypersensitive to rizatriptan, concomitant use of another 5-HT1 agonist, ergotamine-containing medication or MAO, hemiplegic or basilar migraine.

II) LONG TERM TREATMENT: prophilaxys

Amitriptyline 12,5 mg nocte + Physiotherapy Exercises andup to 75 mg if no response Cognitive-Behavioural Therapy(add 25 every 3 weeks)

Better if associated: Depression, Chronic pain, Disturbed Sleep, Tension-type headache

or

Propanolol 40-120 mg BD or Atenolol 25-50 mg OD

IF NOT RESPONDING: Amitriptyline + Propanolol

3B) TENSION-TYPE HEADACHE (TTH)

How to recognize TTH?

Can be Chronic (also everyday) Bilateral No aura No nausea or photophobia No pulsation

I) ACUTE TREATMENT:

Ia) Infrequent episodic TTH (-2 days/week)

Paracetamol 1g BD-TDS + Physiotherapy Exercises and Cognitive-Behavioural Therapy or

Ibuprofen 400 mg q3-4h

or Codeine

Ib) Chronic TTH (+2 days/week)

Amitriptyline 12,5 mg nocte + Physiotherapy Exercises andup to 75 mg if no response Cognitive-Behavioural Therapy(add 25 every 3 weeks)

Better if associated: Depression, Chronic pain, Disturbed Sleep, Tension-type headache

or

Propanolol 40-120 mg BD or Atenolol 25-50 mg OD

Symptomatic treatment only for short time (consider a course of Naproxen 220-550 mg BD)

3C) PAIN DISORDER (gastric, back, leg, chest pain etc..)

Definition: Symptoms suggest a physical disorder, not adequately be explained physiologically, esacerbated by stress and psychological problems.

Amitriptyline 25 mg nocte 1/12 + Counseling

If Responding: continue at least 6 monthsIf not responding: + dosage (as in Depression; see Alghoritm 1d)

4) INSOMNIA

A

Also alone if headache is not to much severe and persistent(benefits after 1/12. Continue at least 6/12)

1ST STEP: Sleep Igiene and Relaxation exercises

2nd STEP: Farmacologic Treatment + counseling

I) Difficult fall asleep (no anxiety during day)

ULTRA SHORT-ACTING: Zolpidem 5-10 mg PO nocte Less Dependence, SedationSHORT-ACTING: Alprazolam: 0,25 mg nocte, up to 2 mg

II) Early weakening (often associated with depression):

Not associated with depression: LONG ACTING: Diazepam: 2,5 mg PO nocte, up 5-10 mg

Associated with Depression: Amitriptyline 25 mg nocte 1/12 (as in Depression, see alghoritm 1d)

NB: At first use Benzodiazepines only at need (when patients is in the bed for several hours and cannot sleep in any way) to help non farmacologic interventions.

Afterwards use the lowest effective dose for as short a period as possible (maximum 3 weeks). Then decrease gradually.

Contraindications of Benzodiazepines:

DIAZEPAM: Pregnancy and Breast feeding, Miastenia gravis, respiratory insufficiency ALPRAZOLAM, ZOLPIDEM: Pregnancy and Breast feeding

Common adverse effects of Diazepam: drowsiness, sedation, muscle weakness. Diazepam can adversely affect parameters of driving performance in healthy subjects.

Serious adverse effects of Diazepam: vertigo, headache, confusion, depression, dysarthria, changes in libido, tremor, visual disturbances, urinary retention or incontinence, gastrointestinal disturbances, changes in salivation, and amnesia. Some patients may experience a paradoxical excitation which may lead to hostility, aggression, and disinhibition. Jaundice, blood disorders, and hypersensitivity reactions have been reported rarely. Respiratory depression and hypotension occasionally occur with high dosage and parenteral administration.

5) SUBSTANCE ABUSE DISORDERS

If Severe Insomnia or not response after 1month of non-farmacologic intervention

5A) ALCOL ABUSE AND DEPENDENCE DISORDER

I) if severe Disorder and high patients motivation:Refer for Rehabilitation in Mathari Hospital inpatients (1200 Sh per day)

II) Acute treatment of Withdrawal symptoms:

IIa) Mild withdrawal: anxiety, insomnia, headache and agitation

-Resolve without need for medication.

IIb) Moderate/Severe Withdrawal: severe anxiety, agitation, insomnia, headache, tremors, sweating, tachycardia, hypertension, and hallucinations, seizures and delirium (delirium tremens).

Diazepam 5-10 mg TDS 3/7 (up to 20 mg, depending + Thiamine 100 mg IM 5/7; then PO 6/12 on the severity of withdrawal) + Potassium, magnesium PO 3/52 and zinc supplementation

Diazepam 5-10 mg BD 3/7

Patients should be placed in low stimulus environments (i.e quiet and dimly lit) and given adequate rehydration. Patients should not be given dextrose before thiamine.

5B) DRUG ABUSE AND DEPENDENCE DISORDER

Refer to Mathari Hospital for psychiatric Consultation or in patients Rehabilitation (1200 Sh per day)

6) SCHIZOPHRENIA:

Schizophrenia is the most common primary psychosis. It is a severe disorder that typically begins in late adolescence or early adulthood; it is found approximately equally in men and women, though the onset tends to be later in women, who also tend to have a better course and outcome of this disorder. Epidemiological surveys report a point prevalence of 0.4%.Schizophrenia is characterized by fundamental distortions in thinking and perception, and by inappropriate emotions. The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness and self-direction. Behaviour may be seriously disturbed during some phases of the disorder, leading to adverse social consequences. Delusions (strong belief in ideas that are false and without any basis in reality), and hallucinations (commonly auditory hallucinations, e.g. hearing voices) are typical psychotic features of this disorder. Individuals with schizophrenia are usually well oriented to person, place and time.

Severely disturbed patients:

Chlorpromazine 100-200 mg IM and then PO 100-200 12-24 hourly

Mildly disturbed patients

Haloperidol 5 mg TDSor Chlorpromazine 100 mg TDS

Maintenance theraphy:

Haloperidol 5-10 mg TDSorChlorpromazine 100-200 TDS

At onset of extrapiramidal effects: reduce dose and start on benzhexol 2,5-5 mg TDS

If concomitant affective symptomatology (alternance of MDE and hypomanic/manic episode) it’s a Schizoaffective Disorder :

- Add Carbamazepine as Maintenance theraphy (see 1b.I) with or without Haloperidol.

These guidelines has been written for Ruaraka Uhai Neema Hospital (http://www.runeemahospital.org/) in collaboration between Jean-louis Aillon (Ruaraka Uhai

Neema Hospital) and Prof. David M. Ndetei (African Mental Health Foundation: http://www.africamentalhealthfoundation.org/).They are an adaptation of the WHO guidelines for Mental health primary care

(http://www.who.int/entity/mental_health/management/psychotropic/en/index.html) to the Kenyan context. The medicines used are the most cost-effective.