Moderate-Severe Depression

In typical depressive episodes, the person experiences depressed mood, loss of interest and enjoyment, and reduced energy leading to diminished activity for at least 2 weeks. Many people with depression also suffer from anxiety symptoms and medically unexplained somatic symptoms.

Ths module covers moderate-severe depression across the lifespan, including childhood, adolescence, and old age.

A person in the mhGAP-IG category of Moderate-Severe Depression has difficulties carrying out his or her usual work, school, domestic or social activities due to symptoms of depression.

The management of symptoms not amounting to moderate-severe depression is covered within the module on Other Significant Emotional or Medically Unexplained Somatic Complaints. » OTH

Of note, people currently exposed to severe adversity often experience psychological difficulties consistent with symptoms of depression but they do not necessary have moderate-severe depression. When considering whether the person has moderate-severe depression, it is essential to assess whether the person not only has symptoms but also has difficulties in day-to-day functioning due to the symptoms.


Psychosis is characterized by distortions of thinking and perception, as well as inappropriate or narrowed range of emotions. Incoherent or irrelevant speech may be present. Hallucinations (hearing voices or seeing things that are not there),delusions (fixed, false idiosyncratic beliefs) or excessive and unwarranted suspicions may also occur. Severe abnormalities of behaviour, such as disorganized behaviour, agitation, excitement and inactivity or overactivity, may be seen. Disturbance of emotions, such as marked apathy or disconnect between reported emotion and observed affect (such as facial expressions and body language), may also be detected. People with psychosis are at high risk of exposure to human rights violations.

Bipolar Disorder

Bipolar disorder is characterized by episodes in which the person's mood and activity levels are significantly disturbed. This disturbance consists on some occasions of an elevation of mood and increased energy and activity (mania), and on others of a lowering of mood and decreased energy and activity (depression). Characteristically, recovery is complete between episodes. People who experience only manic episodes are also classified as having bipolar disorder.

Epilepsy / Seizures

Epilepsy is a chronic condition, characterized by recurrent unprovoked seizures. It has several causes, it may be genetic or may occur in people who have a past history of birth trauma, brain infections or head injury. In some cases, no specific cause can be identified. Seizures are caused by abnormal discharges in the brain and can be of different forms; people with epilepsy can have more than one type of seizure. The two major forms of seizures are convulsive and non-convulsive. Non-convulsive epilepsy has features such as change in awareness, behaviour, emotions or senses (such as taste, smell, vision or hearing) similar to mental health conditions, so may be confused with them. Convulsive epilepsy has features such as sudden muscle contraction, causing the person to fall and lie rigidly, followed by the muscles alternating between relaxation and rigidity, with or without loss of bowel or bladder control. This type is associated with greater stigma and higher morbidity and mortality. This module covers only convulsive epilepsy.

Developmental Disorders

Developmental disorder is an umbrella term covering disorders such as intellectual disability / mental retardation as well as pervasive developmental disorders including autism. These disorders usually have a childhood onset, impairment or delay in functions related to central nervous system maturation, and a steady course rather than the remissions and relapses that tend to characterize many other mental disorders. Despite a childhood onset, the developmental disorders tend to persist into adulthood. People with developmental disorders are more vulnerable to physical illness and to develop other priority conditions mentioned in the mhGAP-IG and require additional attention by health-care providers.

Intellectual disability:

Intellectual disability is characterized by impairment of skills across multiple developmental areas (i.e., cognitive, language, motor and social) during the developmental period. Lower intelligence diminishes the ability to adapt to the daily demands of life. Intelligence Quotient (IQ) tests can provide guidance to the person’s abilities, but should be used only if the tests have been validated for use in the population in which they are being applied.

Pervasive developmental disorders including autism:

The features are impaired social behaviour, communication and language, and a narrow range of interests and activities that are both unique to the individual and carried out repetitively. They originate in infancy or early childhood. Usually, but not always, there is some degree of intellectual disability. Behaviours mentioned above are often seen in individuals with intellectual disabilities as well.

Behavioural Disorders

“Behavioural disorders” is an umbrella term that includes more specific disorders, such as hyperkinetic disorder or attention deficit hyperactivity disorder (ADHD) or other behavioural disorders. Behavioural symptoms of varying levels of severity are very common in the population. Only children and adolescents with a moderate to severe degree of psychological, social, educational or occupational impairment in multiple settings should be diagnosed as having behavioural disorders. For some children with behavioural disorders, the problem persists into adulthood.

Hyperkinetic disorder / attention deficit hyperactivity disorder (ADHD)

The main features are impaired attention and overactivity. Impaired attention shows itself as breaking off from tasks and leaving activities unfinished. The child or adolescent shifts frequently from one activity to another. These deficits in persistence and attention should be diagnosed as a disorder only if they are excessive for the child or adolescent’s age and intelligence, and affect their normal functioning and learning. Overactivity implies excessive restlessness, especially in situations requiring relative calm. It may involve the child or adolescent running and jumping around, getting up from a seat when he or she was supposed to remain seated, excessive talkativeness and noisiness, or fidgeting and wriggling. The characteristic behavioural problems should be of early onset (before age 6 years) and long duration (> 6 months),and not limited to only one setting.

Other behavioural disorders

Unusually frequent and severe temper tantrums and persistent severe disobedience may be present. Disorders of conduct may be characterized by a repetitive and persistent pattern of dissocial, aggressive or defiant conduct. Such behaviour, when at its most extreme for the individual, should be much more severe than ordinary childish mischief or adolescent rebelliousness. Examples of the behaviours may include: excessive levels of fighting or bullying; cruelty to animals or other people; fire-setting; severe destructiveness to property; stealing; repeated lying and running away from school or home. Judgements concerning the presence of other behavioural disorders should take into account the child or adolescent’s developmental level and duration of problem behaviours (at least 6 months).


Dementia is a syndrome due to illness of the brain, which is usually chronic and progressive in nature. The conditions that cause dementia produce changes in a person’s mental ability, personality and behaviour. People with dementia commonly experience problems with memory and the skills needed to carry out everyday activities. Dementia is not part of normal ageing. Although it can occur at any age, it’s more common in older people.

People with dementia often present with complaints of forgetfulness or feeling depressed. Other common symptoms include deterioration in emotional control, social behavior or motivation. People with dementia may be totally unaware of these changes and may not seek help. Sometimes it is thus the family who seeks care. Family members may notice memory problems, change in personality or behaviour, confusion, wandering or incontinence. However some people with dementia and their carers may deny or minimize the severity of memory loss and associated problems.

Dementia results in decline in intellectual functioning and usually interferes with activities of daily living, such as washing, dressing, eating, personal hygiene and toilet activities.

Alcohol Use and Alcohol Use Disorders

Conditions resulting from different patterns of alcohol consumption include acute alcohol intoxication, harmful alcohol use, the alcohol dependence syndrome, and the alcohol withdrawal state. Acute intoxication is a transient condition following intake of alcohol resulting in disturbances of consciousness, cognition, perception, affect or behaviour. Harmful use of alcohol is a pattern of alcohol consumption that is causing damage to health. The damage may be physical (e.g. liver disease) or mental (e.g. episodes of depressive disorder). It is often associated with social consequences (e.g. family problems, or problems at work).

Alcohol dependence is a cluster of physiological, behavioural and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that once had greater value. The alcohol withdrawal state refers to a group of symptoms that may occur upon cessation of alcohol after its prolonged daily use.

Drug Use and Drug Use Disorders

Conditions resulting from different patterns of drug use include acute sedative overdose, acute stimulant intoxication or overdose, harmful or hazardous drug use, cannabis dependence, opioids dependence, stimulant dependence, benzodiazepine dependence, and their corresponding withdrawal states.

Harmful use of drugs is a pattern of drug consumption that is causing damage to health. The damage may be physical (as in cases of infections related to drug use) or mental (e.g. episodes of depressive disorder) and is often associated with damage to social functioning (e.g. family problems, legal problems or work-related problems).

Drug dependence is a cluster of physiological, behavioural and cognitive phenomena in which drug use takes on a much higher priority for a given individual than other behaviours that once had greater value.

The drug withdrawal state refers to group of symptoms occurring upon cessation of a drug after its prolonged daily use.

Self-harm / Suicide

Suicide is the act of deliberately killing oneself. Self-harm is a broader term referring to intentional self-inflicted poisoning or injury, which may or may not have a fatal intent or outcome. Any person over 10 years of age experiencing any of the following conditions should be asked about thoughts or plans of self-harm in the last month and about acts of self-harm in the last year:

  • any of the other priority conditions (see mhGAP-IG Master Chart);
  • chronic pain;
  • acute emotional distress.

Evaluate thoughts, plans and acts of self-harm during the initial evaluation and periodically thereafter as required. Attend to the person’s mental state and emotional distress.

Other Significant Emotional or Medically Unexplained Complaints

People in the mhGAP-IG category “Other Significant Emotional or Medically Unexplained Complaints” have anxiety, depressive or medically unexplained somatic symptoms. They do not have any of the conditions covered elsewhere in this document (except possibly for the condition self-harm). People in this category may experience either “normal” distress or a mental disorder not covered in the mhGAP-IG (e.g. somatoform disorder, mild depression, dysthymia, panic disorder, generalized anxiety disorder, post-traumatic stress disorder, acute stress reaction, adjustment disorder).

The management of “Other Significant Emotional or Medically Unexplained Complaints” by practitioners trained in mhGAP-IG excludes psychotropic medications. Nonetheless, a subset of people in this category may benefit from medication prescribed by a qualified practitioner trained in diagnosis and evidence-based treatment of conditions not covered in this Intervention Guide.

Advanced Psychosocial Interventions

For the purposes of the mhGAP-IG, the term "advanced psychosocial intervention" refers to an intervention that takes more than a few hours of a health-care provider's time to learn and typically more than a few hours to implement. Such interventions can be implemented in non-specialized care settings, but only when sufficient human resource time is made available.