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Mental Health and Psychosocial Support (MHPSS) In Humanitarian Emergencies: What Should General Health Coordinators Know?1 1. Background This document has been prepared for general health coordinators working at national and sub-national level in low and middle income countries. These include national-level Health Cluster members, such as general health coordinators for government, UN and non-UN international agencies and local NGO health programmes. This document is largely based on the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007). It will likely be sufficient for general health coordinators (who have numerous responsibilities beyond mental health) to know the contents of this document. However mental health coordinators, need to be familiar with the entire IASC Guidelines and be skilled and experienced in public mental health in general. The composite term mental health and psychosocial support (MHPSS) is used here to describe any type of local or outside support that aims to protect or promote psychosocial well-being and/or prevent or treat mental disorder. Social supports are essential to protect and support mental health and psychosocial well-being in emergencies, and they should be organized through multiple sectors (e.g., camp management, education, food security and nutrition, health, protection, shelter, and water and sanitation). General health coordinators are encouraged to promote the IASC Guidelines and its key messages to colleagues from other disciplines/sectors/clusters to ensure that there is appropriate action to address the social risk factors affecting mental health and psychosocial well-being. Essential psychological and psychiatric interventions need to be made available for specific, urgent problems. These latter interventions should only be implemented under the leadership of mental health professionals, who tend to work for health sector agencies. 2. Impact of emergencies (IASC Guidelines, pages 2 to 5) Emergencies create a wide range of problems experienced at the individual, family, community and societal levels. At every level, emergencies erode protective supports that are normally available, increase the risks of diverse problems and tend to amplify pre-existing problems. Mental health and psychosocial problems in emergencies are highly interconnected, yet may be predominantly social or psychological in nature. Significant problems of a predominantly social nature include: Pre-existing (pre-emergency) social problems (e.g. belonging to a group that is discriminated against or marginalised; political oppression); Emergency-induced social problems (e.g. family separation; disruption of social networks; destruction of livelihoods, community structures, resources and trust); and Humanitarian aid-induced social problems (e.g. undermining of community structures or traditional support mechanisms). Similarly, problems of a predominantly psychological nature include: Pre-existing problems (e.g. severe mental disorder; depression, alcohol abuse); Emergency-induced problems (e.g. grief, non-pathological distress; alcohol abuse; depression and anxiety disorders, including post-traumatic stress disorder (PTSD)); and Humanitarian aid-related problems (e.g. anxiety due to a lack of information about food distribution; aid dependency). Thus, mental health and psychosocial problems in emergencies encompass far more than the experience of PTSD or disaster-induced depression. A selective focus on these 2 disorders risks ignoring many other MHPSS problems in emergencies. Affected groups have assets or resources that support mental health and psychosocial well-being. A common error in work on mental health and psychosocial well-being is to ignore these resources and to focus solely on deficits – the weaknesses, suffering and pathology – of the affected group. It is important to not only know the 1 For correspondence, please contact IASCmhpss@who.int; IASCmhpss@unicef.org or IASCmhpss@tdh.ch. problems but also the nature of local resources, whether they are helpful or harmful, and the extent to which affected people can access them. 3. Principles (IASC Guidelines pages 9 to 13) The IASC Guidelines are based on 6 principles: human rights and equity, participation, do no harm, building on available resources and capacities, integrated support systems, and multi-layered supports. As is true for other topics in humanitarian aid, health and non-health sector actors should promote human rights and maximise fairness in the availability and accessibility of MHPSS among affected populations, across demographic groups and localities, according to identified needs. Similarly, they should promote the participation of local affected populations in the humanitarian response (See IASC Guidelines sheet 5.1). Many key supports come from affected communities themselves rather than from outside agencies (See IASC Guidelines sheet 5.2). Work on MHPSS has the potential to cause harm because it deals with highly sensitive issues, and, accordingly, a focus on avoiding harm is even more important in MHPSS work than in other areas of aid. A key principle, even in the early stages of an emergency, is building local capacities, supporting self-help and strengthening the resources already present. Where possible, humanitarian actors need to build both government and civil society capacities. At each layer of the pyramid (Figure 1), key tasks are to identify, mobilise and strengthen the skills and capacities of individuals, families, communities and society. Activities and programming should be integrated as far as possible. Proliferation of stand-alone services, such as those dealing only with rape survivors or only with people with a specific diagnosis, tend to be ill advised as they can create a highly fragmented support system. Activities that are integrated into wider systems (e.g. existing community support mechanisms, formal/non-formal school systems, general health services, general mental health services, social services, etc.) tend to reach more people, often are more sustainable, and tend to carry less stigma. In emergencies, people are affected in different ways and require different kinds of supports. A key to organising MHPSS is to develop a layered system of complementary supports that meets the needs of different groups (Figure 1). All layers of the pyramid are important and should ideally be implemented concurrently. Figure 1. Intervention pyramid for mental health and psychosocial support in emergencies. (for an explanation of the different layers, see pages 12-13 of IASC Guidelines) Basic services and security provided in a way that 4. Overview of core interventions and supports during emergencies A number of minimum responses need to be implemented. These interventions are summarized in Table 1. Core activities for health sector involvement are highlighted in italic blue. Where feasible, the health sector may also get involved in any of the other actions, especially in areas of community mobilization and support . The IASC Guidelines give guidance on how each of the minimum responses may be implemented. Table 1: IASC Guidelines Minimum Responses in the Midst of Emergencies (IASC Guidelines pages 20-29) 1.1 Establish coordination of intersectoral mental health and psychosocial support 2.1 Conduct assessments of mental health and psychosocial issues 2.2 Initiate participatory systems for monitoring and evaluation 3.1 Apply a human rights framework through mental health and psychosocial support 3.2 Identify, monitor, prevent and respond to protection threats and failures through social protection 3.3 Identify, monitor, prevent and respond to protection threats and abuses through legal protection 4.1 Identify and recruit staff and engage volunteers who understand local culture 4.2 Enforce staff codes of conduct and ethical guidelines 4.3 Organise orientation and training of aid workers in mental health and psychosocial support 4.4 Prevent and manage problems in mental health and psychosocial well-being among staff and B. Core mental health and psychosocial supports 5 5.1 Facilitate conditions for community mobilisation, ownership and control of emergency response in 5.2 Facilitate community self-help and social support 5.3 Facilitate conditions for appropriate communal cultural, spiritual and religious healing practices 5.4 Facilitate support for young children (0–8 years) and their care-givers 6.1 Include specific psychological and social considerations in provision of general health care 6.2 Provide access to care for people with severe mental disorders 6.3 Protect and care for people with severe mental disorders and other mental and neurological 6.4 Learn about and, where appropriate, collaborate with local, indigenous and traditional health 6.5 Minimise harm related to alcohol and other substance use 7.1 Strengthen access to safe and supportive education 8.1 Provide information to the affected population on the emergency, relief efforts and their legal rights 8.2 Provide access to information about positive coping methods 9.1 Include specific social and psychological considerations (safe aid for all in dignity, considering cultural practices and household roles) in the provision of food and nutritional support 10.1 Include specific social considerations (safe, dignified, culturally and socially appropriate assistance) in site planning and shelter provision, in a coordinated manner 11.1 Include specific social considerations (safe and culturally appropriate access for all in dignity) in The sections below describe a few selected points that are particularly relevant to general health coordinators. Coordination (IASC Guidelines pages 33-37). Coordination of humanitarian aid is a well-known challenge, and coordination of MHPSS is notoriously difficult. This is because of institutionalized divisions in the humanitarian world. In most emergencies, two broad approaches emerge: (a) one focused on clinical assistance through the health sector (e.g., coordinated by Ministry of Health) and (b) one focused on community self-help and social support activities organized by people working in the protection/social sector (e.g. coordinated by Ministry of Social Welfare). Often these complementary approaches develop into independent sets of activities that compete for funding and influence. In numerous crises, this schism has led to separate coordination groups that typically do not communicate with one other. Bridging the gap between health sector's ‘mental health’ programming and the protection/social sector's ‘psychosocial’ programming is a key challenge in many emergencies. An essential point is that the Health and Protection Clusters need to collaborate in organizing one overall coordination group of MHPSS across sectors. Politically and practically it may work best to have such overall group be co-chaired by both a health agency and a protection agency. In large emergencies, the overall coordination group may contain specific subgroups to address specific issues (such as mental health care in health services, child friendly spaces, psychosocial support in schools, etc). The co-chairs of the overall group would then ensure that members of the sub-groups talk to one other to facilitate a coordinated system of support. The overall MHPSS coordination group would report both to the Health and the Protection Cluster, who together would share overall responsibility. The MHPSS coordination group should coordinate with all relevant sectors or IASC Clusters to ensure that their activities are conducted in a way that promotes mental health and psychosocial well-being and that relevant MHPSS actions are undertaken by actors in these Clusters. MHPSS coordination groups should be led where possible by one or more national organisation(s), with appropriate technical support from international organisations. Lead organisations should be knowledgeable in MHPSS and skilled in inclusive coordination processes (e.g. avoiding dominance by a particular approach and sector). Lead organisations need to work to reduce power differences between members of the coordination group and to facilitate the participation of under-represented or less powerful groups (e.g. by using local languages and considering the structure and location of meetings). The IASC guidelines describe in detail key tasks and strategies in coordinating MHPSS. Assessment (IASC Guidelines pages 38 to 45). As in other areas of aid, assessments need to be coordinated. Organisations should first determine what assessments have been done and design further field assessments only if they are necessary. In most emergencies, different groups (government departments, UN organisations, NGOs, etc.) will collect information on different aspects of MHPSS (Table 2) in a range of geographical areas. The coordination group should help to identify which organisations will collect which kinds of information, and where. The group should ensure as far as possible that all the information outlined in the table is available for the affected area. Table 2: Summary of key information for assessments Type of • Access to basic physical needs (e.g. food, shelter, water and sanitation, health care) • Human rights violations and protective frameworks • Social, political, religious and economic structures and dynamics • Changes in livelihood activities and daily community life • Basic ethnographic information on cultural resources, norms, roles and attitudes • Local people’s experiences of the emergency (perceptions of events and their importance, perceived causes, expected consequences) • Signs of psychological and social distress, including behavioural and emotional • Disruption of social solidarity and support mechanisms • Information on people with severe mental disorders • Ways people help themselves and others • Ways in which the population may previously have dealt with adversity • Types of social support and sources of community solidarity • Structure, locations, staffing and resources for mental health care in the health sector (see WHO Mental Health Atlas)and the impact of the emergency on services • Structure, locations, staffing and resources of psychosocial support programmes in education and social services and the impact of the emergency on services • Mapping psychosocial skills of community actors • Mapping of potential partners and the extent and quality/content of previous MHPSS • Mapping of emergency MHPSS programmes • Extent to which key actions outlined in IASC guidelines are implemented • Functionality of referral systems between and within health and other , social, education, General principles of rapid participatory assessment apply when collecting the information summarized in Table 2. Relevant qualitative methods of data collection include literature review, group activities (e.g. focus group discussions), key informant interviews, observations and site visits. Quantitative methods, involving short questionnaires and reviews of existing data in health systems, can also be helpful. Despite their popularity, surveys that seek to assess the distribution of rates of emergency-induced mental disorders tend to be challenging, resource-intensive and, frequently, controversial. Experience has shown that it requires considerable expertise to conduct surveys of mental disorders in a sound and sufficiently rapid manner to substantially and meaningfully influence programmes in the midst of an emergency. Although well-conducted surveys of mental disorders may be part of a comprehensive response, such surveys, according to the IASC Guidelines, go beyond minimum responses, which are defined as essential, high-priority responses that should be implemented as soon as possible in an emergency. For a more detailed discussion on the issue of surveys and the difficulties in distinguishing disorder from distress, please see page 45 of the IASC Guidelines. PHC data collection systems (IASC Guidelines sheet 6.2). The emergency primary health care (PHC) data collection system should collect routine patient data on mental health. PHC staff should be taught to document mental health problems, using simple categories that require little instruction for recognition. The average PHC worker will require little guidance in use of the following 5 categories Medically unexplained somatic complaints Severe emotional distress (e.g. signs of severe grief or severe stress) Severe abnormal behaviour (described on the PHC form in locally understood terms for ‘madness’) Medications. Adequate supplies of essential psychiatric drugs need to be ensured (IASC Guidelines sheet 6.2). General health coordinators should know that: Overall, generic off-patent medicines are recommended, because, in general, they tend to be many-fold cheaper and as effective as patented psychotropics. The minimum provision is one anti-psychotic, one anti-Parkinsonian drug (to manage potential extra-pyramidal side effects), one anti-convulsant/anti-epileptic, one anti-depressant and one anxiolytic (for use with severe substance abuse and convulsions), all in tablet form, from the WHO Model List of Essential Medicines (See Appendix A). The Interagency Emergency Health Kit (2006) does not include (a) an anti-psychotic in tablet form, (b) an anxiolytic in tablet form, (c) an anti-Parkinsonian nor (d) an anti-depressant. Arrangements for either purchasing these drugs locally or importing them will be necessary if this kit is used. Psychological considerations in general health care (IASC Guidelines sheet 6,.1). These include: Communicating to patients, giving clear and accurate information on their health status and on relevant services inside/outside the health sector. A refresher on communicating could include basic knowledge on how to deliver bad news in a supportive manner and how to deal with angry, very anxious, suicidal, psychotic or withdrawn patients; and how to respond to the sharing of extremely private and emotional events; Supporting problem management and empowerment by helping people to clarify their problems, brainstorming together on ways of coping, identifying choices and evaluating the value and consequences of choices; Referral to tracing, social and legal services and to stimulation programmes for undernourished children. Non-pharmacological management of medically unexplained somatic complaints Psychological first aid (PFA). All aid workers, and especially health workers, should be able to provide very basic PFA, which involves a non-clinical, humane, supportive response to a fellow human being who is suffering and who may need support immediately after an extremely stressful event . PFA entails basic, non-intrusive pragmatic care with a focus on: listening but not forcing talk; assessing needs and ensuring that basic needs are met; encouraging but not forcing company from significant others; and protecting from further harm. PFA is very different from psychological debriefing in that it does not necessarily involve a discussion of the event that caused the distress. Psychological debriefing is a popular but controversial technique (which at best is ineffective) and should not be implemented. Clinical treatment. In a minority of cases, when emergency-induced severe, acute distress limits basic functioning or is intolerable, clinical treatment will probably be needed (for guidance, see Where There is No Psychiatrist). With regards to clinical treatment of acute distress, benzodiazepines are greatly over-prescribed in most emergencies. However, this medication may be appropriately prescribed for a very short time for certain clinical problems (e.g. severe insomnia). Caution is required as use of benzodiazepines can quickly lead to dependence. In a minority of cases, a chronic mood or anxiety disorder (including severe presentations of post-traumatic stress disorder) will develop. If the disorder is severe, then it should be treated by a trained clinician as part of the minimum emergency response (described in IASC action sheet 6.2). If the disorder is not severe (e.g. the person is able to function and tolerate the suffering), then the person should receive appropriate care as part of a more comprehensive aid response. Where appropriate, support may be given by trained and clinically supervised community health workers (e.g. social workers, counsellors) attached to health services. Care of the severe mentally ill (Action Sheet 6.2). These disorders often pre-date the emergency but also may have been induced by the emergency. People with such disorders are extremely vulnerable and are often abandoned in emergencies. The action sheet describes a range of aspects of how care for the severe mentally ill may be organized (e.g., assessment issues, training and supervision issues, advertising the service, informing the population about the service). Possible service models for organizing mental health care in PHC include: (a) Mental health professionals attaching themselves to government/NGO PHC teams; (b) Training and supervising local PHC staff to integrate mental health care into normal practice and to (c) Training and supervising one member of the local PHC team (a doctor or a nurse) to provide full- time mental health care alongside the other PHC services. People in institutions (IASC Guidelines sheet 6.3). Patients in mental hospitals have been forgotten or abandoned in various emergencies leading to them being the victims of violence, neglect and human rights violations. Health leaders needs to check on people in institutions and address urgent needs ensuring that people are protected and cared for. Linking with other healing systems (IASC Guidelines sheet 6.4). It is often important to learn about and, where appropriate, collaborate with local, indigenous and traditional healing system. Whether or not traditional healing approaches are clinically effective or harmful (which tends to vary), dialogues with traditional healers can lead to a range of positive outcomes, including increased understanding of affected people's spiritual, psychological and social worlds and improved referral systems, among others. Some traditional healers may avoid collaboration. At the same time, health staff may be unsympathetic or hostile to traditional practices, or may be ignorant of them. Although in some situations keeping a distance may be the best option, the key actions outlined in sheet 6.4 may facilitate a constructive bridge between different systems of care. Alcohol and drugs (IASC Guidelines sheet 6.5). The health sector in collaboration with other sectors may need to act to minimise harm related to alcohol and other substance use in emergencies where their use leads to far-reaching protection, medical or socio-economic problems. The IASC Guidelines outline initial steps in an emergency to minimize harm related to alcohol and other substance use. These steps include assessments, prevention of harmful use and dependence, harm reduction interventions in the community, and management of withdrawal 5. Operational challenges (IASC Guidelines pages 14 and 15) Experience from many different emergencies indicates that some actions are advisable, whereas others should typically be avoided (see Table 3). These do's and don’t's include challenges for the general health coordinator and to mental health coordinators. The general health coordinator should be familiar with these do's and don’t's and may use them as a checklist for programme development, implementation and monitoring. Table 3: Do's and don't's Establish one overall coordination group on mental health Do not create separate groups on mental health or on psychosocial support that do not talk or coordinate with one another. Support a coordinated response, participating in Do not work in isolation or without thinking how one’s own coordination meetings and adding value by complementing the work of others. Collect and analyse information to determine whether a Do not conduct duplicate assessments or accept response is needed and, if so, what kind of response. preliminary data in an uncritical manner. Tailor assessment tools to the local context. Do not use assessment tools not validated in the local, emergency-affected context. Recognise that people are affected by emergencies in Do not assume that everyone in an emergency is different ways. More resilient people may function well, traumatised, or that people who appear resilient need no whereas others may be severely affected and may need specialised supports. Ask questions in the local language(s) and in a safe, Do not duplicate assessments or ask very distressing supportive manner that respects confidentiality. questions without providing follow-up support. Do not assume that emergencies affect men and women (or boys and girls) in exactly the same way, or that programmes designed for men will be of equal help or accessibility for women. Check references in recruiting staff and volunteers and Do not use recruiting practices that severely weaken build the capacity of new personnel from the local and/or affected community. After trainings on MHPSS, provide follow-up supervision Do not use one-time, stand-alone trainings or very short and monitoring to ensure that interventions are trainings without follow-up if preparing people to perform Facilitate the development of community-owned, managed Do not use a charity model that treats people in the community mainly as beneficiaries of services. Build local capacities, supporting self-help and Do not organise supports that undermine or ignore local strengthening the resources already present in affected groups. Learn about and, where appropriate, use local cultural Do not assume that all local cultural practices are helpful or that all local people are supportive of particular practices. Use methods from outside the culture where it is Do not assume that methods from abroad are necessarily better or impose them on local people in ways that marginalise local supportive practices and beliefs. Build government capacities and integrate mental health Do not create parallel mental health services for specific care for emergency survivors in general health services and, if available, in community mental health services. Organise access to a range of supports, including Do not provide one-off, single-session psychological psychological first aid, to people in acute distress after debriefing for people in the general population as an early intervention after exposure to conflict or natural disaster. Train and supervise primary/general health care workers in Do not provide psychotropic medication or psychological good prescription practices and in basic psychological support without training and supervision. support. Use generic medications that are on the essential drug list Do not introduce new, branded medications in contexts where such medications are not widely used. Establish effective systems for referring and supporting Do not establish screening for people with mental disorders without having in place appropriate and accessible services to care for identified persons. Develop locally appropriate care solutions for people at risk Do not institutionalise people (unless an institution is temporarily an indisputable last resort for basic care and protection). Use agency communication officers to promote two-way Do not use agency communication officers to communicate communication with the affected population as well as with the outside world. Use channels such as the media to provide accurate Do not create or show media images that sensationalise information that reduces stress and enables people to people’s suffering or put people at risk. access humanitarian services. Seek to integrate psychosocial considerations as relevant Do not focus solely on clinical activities in the absence of a into all sectors of humanitarian assistance. 6. Post-emergency recovery activities by the health sector The 4-layer pyramid (Figure 1) and multi-sector framework described in this document is also the basis of post-emergency recovery MHPSS work. Recovery activities for different sectors are described in the comprehensive column of the matrix presented on pages 22-29 of the IASC Guidelines. Below is a description of specific activities by the health sector. For the health sector, the most essential post-emergency recovery activities are: Initiate updating of national mental health policy and legislation, as appropriate Develop the availability of mental health care for a broad range of emergency-related and pre-existing mental disorders through general health care and community-based mental health services Work to ensure the sustainability of any newly established mental health services For people in psychiatric institutions, facilitate community-based care and appropriate alternative living It is important to note that a humanitarian emergency is not only a tragedy but also an enormous opportunity to build a mental health system to support people. No matter how one reads the available epidemiological literature, rates of a wide range of mental disorders do go up as a result of emergencies and thus there is a good rational to build long-term, basic, sustainable community mental health services in districts affected by emergencies. All communities in the world should have such services, and especially so if they have been struck by disasters. Examples from Albania, Indonesia, Kosovo, Macedonia, occupied Palestinian territory, Sri Lanka, and Timor-Leste show how an emergency can lead to the long-term development of sustainable mental health care. Although most care should be provided in the community, paradoxically, one of the corner stones of most sustainable district-level mental health systems is a staffed acute psychiatric care inpatient unit. This unit often forms the nucleus of activities to (a) organize community outreach outpatient care throughout the district and (b) support and supervision of much-needed mental health activities in primary health care clinics. Thus, in districts without psychiatric inpatient care, plans for new general hospitals as part of health recovery investment should include planning for a staffed acute psychiatric care inpatient unit. However, post-emergency (re)construction plans sometimes involves building new tertiary-care, mental hospitals. Unfortunately, such plans are typically ill-advised. Decentralization of mental health resources - staff, budgets, and beds - from tertiary care to secondary and primary care is a key strategy when organizing and scaling-up effective treatment coverage of people with mental disorders in the community. Key to sustainable development of mental health care is human resources. Any long term investment in the training of community level staff (doctors, nurses, other PHC workers) should include mental health in the curriculum. 7. Human resources Recruitment. Health agencies may recruit a specific mental health coordinator to coordinate the agency's mental health response. A suggested profile for such person is: Advanced degree in public health/medicine or behavioural/social Good knowledge about MHPSS as emergency response (as Field-based experience in programme management and mental Good knowledge about different cultural attitudes, practices and health & psychosocial support (MHPSS) in humanitarian settings Field-based experience of working within the health sector in low or Good knowledge of the UN and NGO humanitarian community. Appreciation for inter-agency and inter-sectoral collaboration Sheet 4.1 of the IASC Guidelines gives detailed advice on identifying and recruiting any staff or volunteer. General health coordinator should seek recruitment of mental health and psychosocial support providers with knowledge of, and insight into, the local culture and appropriate modes of behaviour. Clinical or any other interpersonal psychosocial support tasks should be performed mainly by local staff. The general health coordinator should use available criteria to carefully evaluate offers of help from individual foreign mental health professionals who may seek to parachute in to offer their services (see IASC Guidelines, pages 72-73). Orientation and training of aid workers in MHPSS. Inadequately oriented and trained workers without the appropriate attitudes and motivation can be harmful to populations they seek to assist. Action sheet 4.3 distinguishes between brief orientation seminars and training. Orientation seminars (half or full-day seminars) should provide immediate basic, essential, functional knowledge and skills relating to psychosocial needs, problems and available resources to everyone working at each level of response. Possible participants include all aid workers in all sectors (particularly from social services, health, education, protection and emergency response divisions). Training seminars - involving the learning of more extensive knowledge and skills - are recommended for those working on focused and specialised MHPSS (see top two layers of the pyramid in Figure 1). The timing of seminars must not interfere with the provision of emergency response. The use of short, consecutive modules for cumulative learning is recommended, because (a) this limits the need to remove staff from their duties for extended periods and (b) it allows staff to practise skills between training sessions. Each short module may last only a few hours or days (according to the situation) and is followed by practice in the field with support and supervision, before the next new module is introduced in a few days’ or weeks’ time. Training seminars should always be followed up with field-based support and/or supervision. Training advanced mental health skills without organizing a system for follow-up is irresponsible. Action sheet 4.3 provides key guidance on organizing orientation and training (e.g., selecting trainers, learning methodologies, content of sessions and challenges in organizing Training of Trainers) Well-being of staff and volunteers. Staff members working in emergency settings tend to work many hours under pressure and within difficult security constraints. Many workers experience insufficient managerial and organisational support, and they tend to report this as their biggest stressor. Moreover, confrontations with horror, danger and human misery are emotionally demanding and potentially affect the mental health and well-being of workers. Action sheet 4.4 (points 2 to 4) describe key actions to facilitate a healthy working environment and addressing potential day-to-day work-related stressors. Psychological debriefing is no longer recommended. Staff who have experienced or witnessed extreme events (critical incidents, potentially traumatic events) need to have access to basic psychological support (psychological first aid (PFA), see above. When survivors’ acute distress is so severe that it limits their basic functioning (or that they are judged to be a risk to themselves or others), they must stop working and receive immediate care by a mental health professional trained in evidence-based treatment of acute traumatic stress. An accompanied medical evacuation may be necessary. It is important to organize that a mental health professional contacts all staff members who have survived a critical incident one to three months following the event. The mental health professional should assess how the survivor is functioning and feeling and make referral to clinical treatment for those with substantial problems that have not healed over time (Action Sheet 4.4, points 6 and 7). 8. Links to tools and key resources for further reading Bolton P. (2001). Cross-Cultural Assessment of Trauma-Related Mental Illness (Phase II). CERTI, Johns Hopkins University, World Vision. http://www.certi.org/publications/policy/ugandafinahreport.htm Forum for Research and Development (2006). Management of Patients with Medically Unexplained Symptoms: Guidelines Poster. Colombo: Forum for Research and Development. http://www.irdsrilanka.org/joomla/ IASC (2005). Action sheet 8.3: Provide community-based psychological and social support. In: Guidelines for Gender-based Violence Interventions in Humanitarian Settings. IASC, pp 69-71. http://www.humanitarianinfo.org/iasc/content/products (also in Arabic, French, & Spanish) IASC (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. IASC. http://www.humanitarianinfo.org/iasc/content/products (also in Arabic, French, & Spanish; hard copy of guidelines includes a CD-ROM with resource documents) PAHO/WHO (2004). Sociocultural aspects. In: Management of Dead Bodies in Disaster Situations, pp.85-106. Washington: PAHO. http://www.paho.org/English/DD/PED/DeadBodiesBook.pdf (also in Spanish) Patel V. (2003). Where There is No Psychiatrist. A Mental Health Care Manual. The Royal College of Psychiatrists. http://www.rcpsych.ac.uk/publications/gaskellbooks/gaskell/1901242757.aspx (a gratis, English-language, electronic copy of the book is available on the CD-ROM of the IASC (2007) Guidelines). Sphere Project (2004). Standard on mental and social aspects of health. In: Humanitarian Charter and Minimum Standards in Disaster Response, pp.291-293. Geneva: Sphere Project. http://www.sphereproject.org/handbook/index.htm (also in Arabic, French, Russian, & Spanish) UNHCR & WHO (2008). Rapid Assessment of Alcohol and Other Substance Use in Conflict-affected and Displaced Populations: A Field WHO (1993). Essential Drugs in Psychiatry. http://whqlibdoc.who.int/hq/1993/WHO_MNH_MND_93.27.pdf WHO (2003), Mental Health in Emergencies: Mental and Social Aspects of Health of Populations Exposed to Extreme Stressors. Geneva: WHO. http://www.who.int/mental_health/media/en/640.pdf (also in Arabic, Bahasa, French, Russian, & Spanish) WHO (2003). Brief Intervention for Substance Use: A Manual for Use in Primary Care. Draft Version 1.1 for Field Testing. Geneva: WHO. http://www.who.int/substance_abuse/activities/en/Draft_Brief_Intervention_for_Substance_Use.pdf (also in Spanish) WHO (2006). Mental Health and Psychosocial Well-being among Children in Severe Food Shortage Situations. Geneva: WHO. http://www.who.int/nmh/publications/msd_MHChildFSS9.pdf (also in French & Spanish). WHO/UNHCR (1996). Mental health of Refugees. Geneva: WHO http://whqlibdoc.who.int/hq/1996/a49374.pdf (also in French, WHO/UNHCR/UNFPA (2004). Clinical Management of Survivors of Rape: Developing Protocols for Use with Refugees and Internally Displaced Persons (revised edition). Geneva: WHO/UNHCR. http://www.who.int/reproductive-health/publications/clinical_mngt_survivors_of_rape/ (also in Arabic & French) Appendix A: Relevant medicines on core list of WHO Model List of Essential Medicines (15th ed., 2007) Section 24. Psychotherapeutic medicines Injection: 25 mg (hydrochloride)/ml in 2‐ml ampoule; oral liquid: 25 mg (hydrochloride)/5 ml; tablet: 100 mg Injection: 25 mg (decanoate or enantate) in 1‐ml ampoule. Injection: 5 mg in 1‐ml ampoule; tablet: 2 mg; 5 mg Capsule or tablet: 20 mg (present as hydrochloride). Tablet (enteric‐coated): 200 mg; 500 mg (sodium valproate) Section 9. Antiparkinsonism medicines (to deal with potential extra-pyramidal side effects of anti-psychotics) biperiden Injection: 5 mg (lactate) in 1‐ml ampoule; tablet: 2 mg (hydrochloride). Section 5. Anticonvulsants/antiepileptics carbamazepine Oral liquid: 100 mg/5 ml; tablet (chewable): 100 mg; 200 mg; tablet (scored): 100 mg; 200 mg. Injection: 5 mg/ml in 2‐ml ampoule (intravenous or rectal). Injection: 200 mg/ml (phenobarbital sodium); oral liquid: 15 mg/5 ml (as phenobarbital or phenobarbital sodium); tablet: 15‐100 mg (phenobarbital). Capsule: 25 mg; 50 mg; 100 mg (sodium salt); injection: 50 mg/ml in 5‐ml vial (sodium salt); oral liquid: 25‐30 mg/5 ml; tablet: 25 mg; 50 mg; 100 mg (sodium salt); tablet (chewable): 50 mg. Oral liquid: 200 mg/5 ml; tablet (crushable): 100 mg; tablet (enteric‐coated): 200 mg; 500 mg (sodium valproate). = similar clinical performance within a broader pharmacological class

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