mhGAP Orientation Workshop
Report
Volunteering & International Psychiatry Special Interest
Group of Royal College of Psychiatrists
http://www.rcpsych.ac.uk/workinpsychiatry/specialinterestgroups/volunteeringa
ndinternational.aspx
9th and 10th March 18th 2013
Springfield University Hospital, London.
Dated 2.4.2013
Dr. Peter Hughes M.B.B.A.O.B.C.h., FRCPsych -author of report
Contact details
Dr. Peter Hughes e-mail: dppmh@hotmail.com
List of abbreviations and acronyms
IG
mhGAP
mhGAP-IG
MNS
NGO
PHC
RCP
ToT
WHO
VIPSIG
Intervention Guide
Mental Health Gap Action Programme
Mental Health GAP Action Programme - Intervention Guide
Mental, Neurological and Substance abuse
Non governmental organisation
Primary Health Care
Royal College of Psychiatrists
Training of Trainers
World Health Organisation
Volunteering and International Psychiatry Special Interest Group
mhGAP Modules Abbreviations
GPC
DEP
PSY
EPI
DEV
BEH
DEM
ALC
DRU
SUI
BPD
OTH
BASE Course
STANDARD
Course
General Principles of Care
Depression
Psychosis
Epilepsy
Developmental Disorders
Behavioural Disorders
Dementia
Alcohol Use and Alcohol Use Disorders
Drug Use and Drug Use Disorders
Suicide and Self-Harm
Bipolar Disorder
Other Significant Emotional or Medically Unexplained Complaints
Modules covered including assessment and some management
advice
Modules covered including assessment and all of management
Acknowledgements
I thank the Adult Faculty of the Royal College of Psychiatrists for supporting this
orientation, Springfield University Hospital for hosting, Sue Duncan at College of
Psychiatry, Dr. Sophia Thomson, Dr. Mandip Jheeta and all participants.
Introduction and objectives of the orientation expercise.
This report describes the mhGAP Orientation Workshop organised
by Dr. Peter Hughes, Dr. Sophia Thomson and Dr. Mandip Jheeta of
the Volunteering and International Psychiatry Special Interest
Group.
The Adult Faculty of the Royal College of Psychiatry generously
donated £5,000 over 2 financial years to establish an mhGAP based
education and support of field-work.
This educational event is the first part of this programme.
mhGAP is a WHO programme initiated in 2008 designed to scale up
care for mental, neurological and substance use disorders among
non-specialist providers, including primary health care. The
objective is to scale up mental health care in resource poor settings
to address the gap in mental health care unmet needs of persons
suffering from MNS disorders.
Objectives of the orientation exercise
Objectives of the orientation
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Introduce mhGAP IG to an audience of UK based mental
health professionals
Generate enthusiasm, future training and field opportunities
Generate familiarity with the mhGAP programme, mhGAP-IG
and the concept of the draft facilitator guides.
Facilitate basic skills of mhGAP working and teaching.
Develop a mind-set that is PHC centred rather than secondary
care.
Teaching skills in mhGAP on assessment, diagnosis and
management of priority conditions
Facilitate General Principles of Care as an overarching concept
that covers all further teaching.
Improve teaching skills amongst the participants by modelling
and active participation.
Master various models of training methodology and training
techniques, facilitator skills and some supervision skills
Communication skills
Focus on development of role-play as a core teaching
methodology in a very practical way.
Generate a body of interest for further projects
Develop momentum for special Interest group
Preparation for conference
The idea for this conference came up at previous VIPSIG meetings
in 2012.
A bid was made to the Adult Faculty of RCP following discussions.
The VIPSIG was successful. It was necessary to make use of the
funding offered within the financial year generating a need to move
fast with Orientation.
The core group of organisers were Dr. Peter Hughes, Sophia
Thomson and Mandip jheeta.
Dr. Peter Hughes had been engaged in some WHO consultancies on
mhGAP programme and was able to use some of that expertise for
generating the programme.
Dr. Sophia Thomson had been involved as well as Dr. Peter Hughes
in Sudan in mhGAP training with WHO and Sudan Ministry of
Health.
A flyer was sent to members of the VIPSIG to invite to attend.
Administration was based through RCP office and thanks to Sue
Duncan for all this work. Others were invited through informal
contacts and word of mouth.
Springfield University Hospital gave a venue for free for the 2-day
event.
20 mhGAP books were purchased from WHO shop Geneva. At end
of 2 days a number of copies were donated to people who were
about to go overseas e.g. Ghana, Mogadishu, Sharjah, Kashmir and
others.
Venue
This was a large room at Springfield University hospital, London. It
was readily accessible by train, car and other transport means.
Venue was adequate in terms of need. Ventilation was adequate.
There was a large attendance so room could get warm during day.
There was no need for microphone although one feedback from one
person of problem with sound.
There was a problem with projector being locked up in room that
wasn’t accessible on Saturday and Sunday. For this reason there
was no PowerPoint possible or demonstration of facilitator guides
except by people looking at computer screens individually.
Attendees
73 people attended on day 1 including organisers and 52 second day.
Most of Day 2 attendees had been to Day 1 as well. Those that had been unable to
attend both days had explained other commitments stopped attendance at full
Orientation.
Attendees had come from a range of places in UK and Northern Ireland. One
person had come from Kashmir.
Attendees were invited to give their discipline background but there is little
information available. At least 40 people day 1 were psychiatrists and 34 day 2.
Other disciples present were nurses, social workers, psychologists, students and
an ethicist.
Countries of interest in attendees were Ghana, Sri Lanka, Gambia, Somaliland,
Nepal, India, Pakistan, Kenya, Malawi and others
There were many representatives of diaspora communities.
Attendees were a broader group than members of VIPSIG.
Attendee list Appendix 1 and 2.
Finance
Venue was free and support for lunches/refreshments and mhGAP IG copies was
facilitated through the finance department of the Royal College of Psychiatrists
funded by Adult Faculty.
Agenda
The agenda was over 2 days as per Appendix 3 below. It was loosely covered but
altered with need and was very flexible.
It was a highly interactive programme with small group work, role-play and
lecture as well as other teaching methods.
General principles of care were emphasised throughout the two days.
Summary of areas covered over 2 days
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Introduction and history of mhGAP programme and IG
mhGAP IG, Masterchart and facilitator guides
General Principles of Care
Depression
Psychosis
Somatisation
Epilepsy
Child conditions
Substance abuse
Organic conditions
Culture
Adaptations
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Teaching skills
Role play skills
General Principles of Care
-Communication skills
o Unit of teaching = role play
-Assessment
o Inc. physical exam
-Treatment
o Inc. HIV, older people, children
-Mobilising social supports
o E.g. religion
-Attention to wellbeing
o E.g. smoking & exercise
-Protection of human rights
o Can be a controversial area e/g/ chaining, beating with stick,
unmodified ECT
Epilepsy & psycho education
This was explicitly covered as an area of least comfort for a UK mental health group.
Epilepsy can be seen as a way of making inroads into combatting stigma against
mental illness as less stigmatised than mental illness and substance use.
It is a good area to teach in the beginning of a training as technical and doctor
friendly area.
In this orientation there was much repetition, which we showed as an educational
tool in its own right.
During this orientation there was some familiarity with epilepsy amongst those who
deal with intellectual disability.
Format was a small group role-play focussing on diagnosis, management and psychoeducation.
Then there was a demonstration role-play in front of all covering emergency
management of seizure. Included were environmental risks.
mhGAP IG on epilepsy has more boxes than other chapters and has a lot of technical
information. It was most familiar territory for doctors. The psycho-education was
more challenging for this topic.
Follow up was discussed as challenging in low resource setting and also an issue in
UK
Problem solving session
This was the main psychosocial intervention emphasised along with psychoeducation.
This is an easy skill to develop with minimal training. Dr. Thomas had some specific
family therapy background in using these principles and demonstrated in role-play.
There was an overall consensus that the problems generated by patients are
universal. Often neglected in primary health care but is very important and
achievable skill.
There was repetition of this with further role-plays to demonstrate the skills.
Some useful starting questions such as “do you have any problems at home”
Model from Dr. Thomas of problem solving
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Explain the problem  get person engaged
Define the problem  help person choose one that matters
List possible solutions  brainstorm all THEIR ideas
Evaluate advantages and disadvantages
Plan how to carry out step by step
Review at specific time
Screening questions Pre mhGAP –
This came out of discussions about how to get into mhGAP. Consensus was to use
the 6 golden questions (V Patel, where there is no psychiatrist)
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6 golden questions (V Patel, where there is no psychiatrist)
This was seen as a very helpful adjunct to mhGAP
1. Do you have any problems sleeping at night?
2. Have you been feeling as if you have lost interest in your usual
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activities?
Have you been feeling sad or unhappy recently?
Have you been feeling scared or frightened of anything?
Have you been worried about drinking too much alcohol recently?
How much money have you been spending on drugs or alcohol
recently?
2 screening interpersonal questions:
1. Economic problems
2. Problems at home
Human rights session
This was a brainstorming session and was a request from participants to have as a
session
Concepts discussed
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“Parity of esteem”
Human rights at primary care
Confidentiality
Clean water
Non-judgmental
Education
Expression
Equal access to health care esp. vulnerable
Childhood/ ADHD
This was another topic that was emphasised. This is an area that all but child health
workers are comfortable with. It is richest in psychosocial interventions.
Parenting tips
We emphasised parenting skills and assembled parenting tips.
We suggested role-plays on this.
Hyperactivity is a common problem worldwide in children
There are different parenting techniques for different children
Likely that there is no simple nuclear family in many LAMI countries
Parenting tips
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Consistency
Reward good behaviour
Good modelling of behaviour
Routines
Commitment
Clear boundaries
Instructions & requests  short & precise
Be fair
Timely intervention
Listening
Quality time
Genuine interest
Constrictive, not punitive punishment
What can go wrong in training session?
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Practical issues -Door to room closed, toothache and other health
problems , visas, getting lost, and participants fall asleep!
No electricity
Not enough or no fans
Weather, transport problems
Programmatically problem is lack of adequate supervision on followup.
People deviate from mhGAP
People cannot task shift to primary care level
How to timetable to programme for one week?
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Day 1 general principles of care
3-4 role plays/ day & 1 other teaching exercise, 1 CBD
Psychosis 1 day
Depression 1 day
Children, behaviour, depression 1 day
Other & somatic 1 day
2 teaching modules/ day
Fit the time, will be shattered by end of day
Model session is start with demonstration role-play, facilitator guide PowerPoint for
20 minutes if facilities available then 2 or more exercises including at least 1 roleplay task.
Sessions reinforced with MCQ questions and recap subsequently.
What works?
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International people & match with local counterpart  for training
the trainers
Ground rules: phone, decide “punishment” for arriving late.
Have student rep
Good Timing
Assume no power supply and manage without Powerpoint if
necessary
Organised Per diem
Organised lunch
Ensure sustainability
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Essentially, investing a lot of time, effort and money
Go through book box-by-box & teach as case based discussion
Supervision and follow up
Size groups
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8 min -14 ideal max. Primary care physicians or nurses
or non-prescribers.
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Where and how to show interest in going to LAMIC to do mhGAP?
-College volunteer programme
-NGOs
-Diaspora groups
Update of RCPsych activities, volunteer scheme
FAQs
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Day-by-Day summary
Saturday
 Introduction, experience & context of mhGAP. Historical account was given.
 General principles of care: CATMAP were discussed
 Introduction to intervention guide
 Demonstration role play- depression
 Role-plays small groups & feedback
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-Depression esp. diagnosis
Role-play demonstration (after lunch)
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-Somatic delusion
-Hypochondriasis
Role play psychosis & feedback esp. management & psychosocial Mx
Feedback, what people want for Sunday
Issues that came up from day 1 orientation:
-Low baseline knowledge of potential trainees
-Not being perfect
-Sometimes conflict with how people taught e.g. fluidity vs. using
checklist
-Reading and training in front of patient
-Low communication skills
-Have manual in front of you for 6/12
-Grey boxes first
-Assessment  decisions  management
-Use master chart
Sunday
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Recap
Epilepsy & psychoeducation
Problem solving
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Human rights
Orientation to primary care setting by demonstration role-play.
Timetabling
What goes wrong
Future plans
Evaluations
Evaluation
Evaluation was overall positive (Appendix 4).
Comments are at end of Appendix 4.
The evaluation form was filled in by a minority of attendees but matched verbal
feedback overall.
Generally people found the mhGAP IG concept helpful and useful.
Some felt that the orientation could have been covered in one day. It was clear
that some of participants found it difficult to shift task and consider a primary
care audience rather than reflecting on their own backgrounds.
There was much positive verbal feedback and requests for further training in
London and outside in UK.
Some attendees planned to use in future projects around the world.
Evaluation Results Table
1
Venue
2. Lunch and
Refreshments
3. Applicable to own
Practice
4. Was training useful
5. Duration
6.
7.
8.
Speakers
Demonstrations
Small group
discussions
9. Learned
10. How useful is mhGAP
in
Primary Care
Excellent 21%
Excellent 3%
Good 73%
Good 75%
Bad 6%
Bad 22%
Yes 79%
No O %
Possible 21%
Yes 97%
About right
78%
Excellent 75%
Excellent 48%
Excellent 58%
No 3%
Too long 18%
Somewhat 0
Too short
6%
Bad 0
Bad 6%
Bad 6%
A lot 73%
Very useful
79%
A bit 27%
Somewhat
21%
Good 25%
Good 45%
39% Good
Nothing 0
Not at all 0
Recommendations and Observations
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There was a lot of interest in having a training on
mhGAP so possibility of further orientation in
London and around UK
Attendees encouraged to register with volunteers
programme at college
Recommend attendees register with VIPSIG if not
already
mhGAP teaching methods are followed
Facilitator guides are used and referenced for
training
Pre and post test KAP in any training
Use MCQs each day of any training
General principles of care is used throughout any
training
Role play as unit of teaching to a great extent
Advise any trainees to use mhGAP Ig in front of them
for at least 6 months even though may seem as bad
practice from communication point of view.
OTH –use practical examples of cases and develop
good psycho-education skills
EPI is a good topic for doctors as a comfortable
area
Important to ensure timetable in chapters that are
less confortable for doctors DEV and BEH
Importance of planning training and discipline of
teaching
Use of golden questions of where there is no
Psychiatrist can easily be incorporated
Problem solving skills are important to use and
train on and achievable easily at primary care level
Parenting skills-important to train on this
Use Masterchart and physical mhGAP Ig copy
constantly, start with grey boxes, role play and
exercises on assessment, treatment, role plays on
psycho-education and other psycho-social
interventions
Importance of supervision to ensure mhGAP is used
Can be adapted for use in UK in primary care
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Advanced psychosocial interventions is problematic
in practice but principles of problem solving,
parenting skills readily achievable in Primary Care.
mhGAP IG available in WHO shop Geneva and also
Blackwells online
Interpersonal therapy can be developed as an easy
and important intervention
All attendees gave permission for their E-mails to
be used in relation to mhGAP trainings