World Health Organization · 3rd edition, 2023 · 184 pages
Evidence-based recommendations for non-specialist health workers to deliver care for priority mental, neurological and substance use conditions in low-resource settings
- Issuer
- World Health Organization
- Edition
- 3rd edition, 2023
- Audience
- Non-specialist health workers (doctors, nurses, community health workers) in primary and secondary care; district-level services; health workers in general health and disease programmes (NCDs, HIV/TB, maternal/child health); policy-makers, programme managers, NGOs in LMICs
- Evidence
- GRADE-rated systematic reviews (48 new/updated recommendations: 2 high certainty, 15 moderate, 19 low, 12 very low); 90 validated recommendations from 2015 edition retained
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
The 2023 mhGAP guideline provides 48 updated and new evidence-based recommendations for managing mental, neurological and substance use (MNS) disorders in non-specialized health-care settings. Covering 11 modules—alcohol use disorders, anxiety, child and adolescent mental disorders, stress-related conditions, dementia, depression, drug use disorders, epilepsy, psychosis and bipolar disorder, self-harm and suicide, plus overarching carer support—the guideline employs GRADE methodology to rate evidence certainty and recommendation strength.
Key updates include conditional recommendations for baclofen post-detoxification and combined pharmacological-psychosocial treatment for alcohol dependence; strong recommendations for brief CBT-based interventions for generalized anxiety disorder and panic disorder; updated antiseizure medicine guidance prioritizing lamotrigine and levetiracetam as first-line monotherapy for epilepsy (avoiding valproate in women and girls of childbearing potential); expanded psychosocial interventions for children with neurodevelopmental conditions; and recognition of digital intervention formats as adjuncts to conventional care. The guideline balances effectiveness, safety, values, equity, feasibility and human rights considerations, explicitly designed for task-sharing with lay and non-specialist health workers in LMICs.
Standing alongside 90 validated recommendations from the 2015 edition, this third update reflects a decade of global implementation in over 100 countries and more than 20 languages, informing the WHO Model List of Essential Medicines and national universal health coverage benefit packages.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Baclofen should be considered for adults with alcohol dependence post-detoxification (moderate certainty); combined psychosocial and pharmacological interventions should be offered (strong recommendation, moderate certainty).
- SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, sertraline) should be considered for adults with generalized anxiety disorder and panic disorder; TCAs if SSRIs unavailable for panic disorder only (conditional, low certainty).
- Brief structured psychological interventions based on CBT principles should be offered for adults with GAD and/or panic disorder (strong, moderate certainty); benzodiazepines not recommended except for emergency use 3–7 days maximum (strong, low certainty).
- For epilepsy, first-line monotherapy: lamotrigine or levetiracetam for generalized onset seizures; lamotrigine or levetiracetam for focal onset seizures (carbamazepine if neither available). Valproic acid contraindicated in women/girls of childbearing potential due to teratogenicity (strong, high certainty).
- Methylphenidate may be considered for children ≥6 years with ADHD only after environmental modifications, by/in consultation with specialist, with close monitoring for weight loss (conditional, low certainty).
- Psychosocial interventions (CBT, IPT, BAT, PST, DYN, 3WV) should be offered for adults with moderate-to-severe depression (strong, moderate certainty); antidepressants alone only when psychological interventions unavailable (conditional, low certainty).
- For adults with psychotic disorders, oral antipsychotics (aripiprazole, chlorpromazine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone) should be offered (strong, moderate certainty); clozapine for treatment-resistant cases under specialist supervision (conditional, moderate certainty).
- Physical exercise (150–300 min/week moderate-intensity aerobic activity) should be offered to people with dementia (strong, high certainty); CBT, cognitive stimulation therapy and cognitive training should be considered (conditional, low certainty).
Summary of new and updated recommendations by module (Table 1 condensed)
Table extracted from the guideline
| Module | Recommendation number | Topic | Strength | Certainty |
|---|---|---|---|---|
| Alcohol (ALC) | ALC1 | Baclofen post-detoxification | Conditional | Moderate |
| Alcohol (ALC) | ALC4 | Combined psychosocial + pharmacological | Strong | Moderate |
| Anxiety (ANX) | ANX1 | SSRIs for GAD/panic disorder | Conditional | Low |
| Anxiety (ANX) | ANX2 | Brief CBT-based interventions | Strong | Moderate |
| Anxiety (ANX) | ANX6 | Benzodiazepines NOT recommended (except 3–7d emergency) | Strong | Low |
| Child/adolescent (CAMH) | CAMH1 | Methylphenidate for ADHD ≥6y (specialist) | Conditional | Low |
| Depression (DEP) | DEP3 | Structured psychological interventions (BAT, CBT, IPT, PST, DYN, 3WV) | Strong | Moderate |
| Epilepsy (EPI) | EPI3 | Lamotrigine/levetiracetam first-line (avoid valproate in women/girls childbearing age) | Strong | High |
| Dementia (DEM) | DEM3.1 | Physical exercise 3–4×/week, 30–45 min, >12 weeks | Strong | High |
| Psychosis (PSY) | PSY1.1 | Oral antipsychotics (7 medicines listed) | Strong | Moderate |
Source: World Health Organization, Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- 48 new and updated evidence-based recommendations (30 updated PICO questions from 2015, 18 new PICO questions including 7 for the new anxiety module).
- New anxiety disorders module (ANX) with 7 recommendations covering SSRIs, TCAs, brief CBT, stress management, physical exercise, benzodiazepines (not recommended), and collaborative care.
- Epilepsy: first-line monotherapy now prioritizes lamotrigine and levetiracetam for both generalized and focal onset seizures; strong recommendation against valproic acid (sodium valproate) in women/girls of childbearing potential due to high teratogenicity risk.
- Alcohol use disorders: new recommendations on digital interventions (conditional, low certainty) and combined treatment (strong, moderate certainty); updated evidence on baclofen and psychosocial interventions.
- Depression: updated evidence synthesis confirms structured psychological interventions (BAT, CBT, IPT, PST, DYN, 3WV) as strong recommendation (moderate certainty); antidepressants alone only when psychological interventions unavailable.
- Child and adolescent mental disorders: expanded coverage of psychosocial interventions for neurodevelopmental disabilities (autism, ADHD, intellectual development, speech disorders) including social skills training, CBT for anxiety in autism, beginning-to-read interventions, and physical exercise; recommendation against antidepressants for anxiety in children and for depression in children ≤12 years.
- Dementia: physical exercise interventions upgraded to strong recommendation with high certainty of evidence (3–4 times/week, 30–45 minutes, >12 weeks).
- Drug use disorders: new recommendations on digital interventions and recovery-oriented services; updated evidence on psychosocial interventions (CBT, contingency management) for cocaine/stimulant dependence.
- New overarching recommendation (OVE1) on psychosocial interventions for carers of persons with psychosis, bipolar disorder or substance use disorder.
- Explicit consideration of digital/online delivery formats across multiple modules (alcohol, drugs, anxiety, self-harm/suicide) with emphasis on ensuring informed consent, safety, confidentiality and not replacing other interventions.
- All recommendations explicitly address implementation considerations including task-sharing feasibility, equity, human rights, sociocultural acceptability and resource requirements for LMICs.
From the guideline
Verbatim
“Valproic acid (sodium valproate) is not recommended in women and girls of childbearing potential owing to the high risk of birth defects and neurodevelopmental disorders in children exposed to valproic acid (sodium valproate) in the womb.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Chair of the Public Health Institute of Georgia and a WHO consultant, I view this third mhGAP edition as a critical roadmap for completing Georgia's decade-long mental health reform. The task-sharing model—enabling family doctors and nurses to manage depression, anxiety and epilepsy—is not aspirational but urgently necessary given our psychiatrist shortage (2.1 per 100,000 population versus European average of 12). I would stress to Georgian clinicians the epilepsy recommendation: immediately stop prescribing valproate to women of childbearing age and switch to lamotrigine or levetiracetam; our 2019 national audit found valproate still used in 38% of such cases, exposing future children to preventable disability. The realistic implementation caveat is supervision capacity. The guideline assumes regular specialist supervision for non-specialists, but outside Tbilisi we have one psychiatrist per 50,000 rural population. Our Ministry of Health must invest in telemedicine supervision platforms and train regional neurologists to supervise epilepsy care before scaling mhGAP nationally. The evidence is strong; our health system readiness remains the bottleneck.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia’s mental health reform since 2013 (community-based services, primary care integration pilot projects) and UHC programme create a receptive environment for mhGAP implementation. The guideline’s task-sharing approach—enabling family doctors, nurses and community health workers to deliver evidence-based MNS care—directly supports Georgia’s ongoing shift from institution-based to community psychiatric services. Priority areas for Georgian adaptation include: (i) integrating brief CBT and problem-solving therapy into the primary care benefit package, leveraging the network of rural ambulatories; (ii) updating national epilepsy protocols to prioritize lamotrigine/levetiracetam and eliminate valproate use in women of childbearing age (currently still prescribed); (iii) developing digital mental health platforms in Georgian language, building on existing telemedicine infrastructure from COVID-19; and (iv) training family doctors in collaborative care models for depression/anxiety in patients with noncommunicable diseases (diabetes, cardiovascular disease). The Public Health Institute of Georgia and the Ministry of Health will need to address workforce capacity (training, supervision), medicine availability (several recommended antipsychotics and newer antiseizure medicines not yet on the national reimbursement list), and cultural adaptation of psychological interventions. The guideline’s human rights emphasis aligns with Georgia’s 2020 Mental Health Care Act but requires stronger enforcement mechanisms to reduce coercive practices still reported in inpatient facilities. Regional collaboration across the South Caucasus (Armenia, Azerbaijan) on mhGAP translation and training would improve cost-efficiency and enable comparative implementation research in similar post-Soviet health systems.
Questions this guideline answers
Quick answers
Can primary care doctors prescribe antidepressants for anxiety without referring to a psychiatrist?
Yes. The guideline recommends SSRIs (citalopram, escitalopram, fluoxetine, paroxetine, sertraline) for adults with generalized anxiety disorder and panic disorder, provided the health worker is competent (qualified, trained, supervised) to prescribe psychotropic medicines. Benzodiazepines are NOT recommended except for emergency management of acute severe anxiety (3–7 days maximum). Close monitoring is essential, especially for adults under 30 (increased suicide risk in first month).
What is the first-line antiseizure medicine for a 25-year-old woman with newly diagnosed epilepsy?
Lamotrigine or levetiracetam as monotherapy (strong recommendation, high certainty). Valproic acid (sodium valproate) must NOT be used in women and girls of childbearing potential due to high risk of birth defects and neurodevelopmental disorders in babies exposed in utero. If lamotrigine and levetiracetam are unavailable, carbamazepine may be considered for focal onset seizures. Refer to specialist if monotherapy unsuccessful.
Should I prescribe methylphenidate for a 7-year-old child with ADHD?
Only after: (i) environmental modifications at school/home have been tried and ADHD symptoms still cause significant impairment; (ii) careful assessment completed; (iii) child and caregivers informed about treatment options; and (iv) prescription made by or in consultation with a specialist. Methylphenidate requires close monitoring for weight loss and other adverse effects. Psychosocial interventions (social skills training, organizational skills training) should be combined when possible.
What non-pharmacological treatment should I offer a patient with moderate depression?
Structured psychological interventions should be offered as first-line treatment: behavioural activation therapy (BAT), cognitive behavioural therapy (CBT), interpersonal therapy (IPT), problem-solving therapy (PST), brief psychodynamic therapy (DYN) or third wave therapies (3WV) (strong recommendation, moderate certainty). Antidepressants alone should only be considered when psychological interventions are unavailable. Combined treatment may be offered based on individual preference and careful consideration of benefits/harms.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 3rd edition, 2023
- Replaces
- mhGAP guideline for mental, neurological and substance use disorders, 2015
- Status
- Current
- Published
- 2023-11-20
- Languages
- English (translated into 20+ languages including Russian, French, Spanish, Arabic)
- Scope
- Mental, neurological and substance use (MNS) disorders: depression, psychosis, bipolar disorder, epilepsy, developmental and behavioural disorders, dementia, alcohol use disorders, drug use disorders, self-harm/suicide, anxiety disorders, stress-related conditions
- Audience
- Non-specialist health workers (doctors, nurses, community health workers) in primary and secondary care; district-level services; health workers in general health and disease programmes (NCDs, HIV/TB, maternal/child health); policy-makers, programme managers, NGOs in LMICs
- Pages
- 184
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 9789240084278
- Evidence
- GRADE-rated systematic reviews (48 new/updated recommendations: 2 high certainty, 15 moderate, 19 low, 12 very low); 90 validated recommendations from 2015 edition retained
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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