World Health Organization · Bangladesh Version 2021 (based on mhGAP-IG Version 2.0, 2016) · 162 pages
Clinical decision-making protocols for primary care and non-specialist health workers managing priority mental health conditions in Bangladesh.
- Issuer
- World Health Organization
- Edition
- Bangladesh Version 2021 (based on mhGAP-IG Version 2.0, 2016)
- Audience
- Primary care doctors, nurses, community health workers, and other non-specialist health-care providers in first- and second-level health facilities in Bangladesh; also useful for mental health specialists.
- Evidence
- Based on mhGAP Evidence Resource Centre reviews; contextualized through expert consensus in consultative workshops with Bangladeshi psychiatrists, neurologists, psychologists, social workers, and Directorate General of Health Services representatives.
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
The mhGAP Intervention Guide (mhGAP-IG) Bangladesh Version 2021 is a contextualized adaptation of WHO’s global mhGAP-IG Version 2.0, designed for primary care doctors, nurses, and community health workers in non-specialized settings. It addresses eight priority mental, neurological, and substance use (MNS) conditions: depression, psychoses (including bipolar disorder), epilepsy, child and adolescent mental and behavioural disorders, dementia, disorders due to substance use, self-harm/suicide, and other significant mental health complaints.
The guide uses a clinical decision-making framework with flowcharts for assessment, detailed management protocols combining psychosocial and pharmacological interventions, and structured follow-up schedules. Each module begins with common presentations, moves through differential diagnosis excluding physical causes, and provides specific dosing regimens (e.g., fluoxetine 10–20 mg daily for depression, carbamazepine starting at 100–200 mg for epilepsy, diazepam 10–20 mg for alcohol withdrawal). The guide emphasizes human rights, informed consent, psychoeducation, family involvement, and linking patients to social services.
Developed through consultative workshops with Bangladeshi psychiatrists, neurologists, psychologists, and the National Institute of Mental Health, the document addresses the country’s mental health gap: 16.8% of adults and 14% of children have psychiatric disorders, yet over 92% receive no care. Cultural adaptations include Bangla terminology for mental distress (‘mon kharap’, ‘mone kosto’), locally available substances (ganja, yaba, phensidyl), and referral pathways through Bangladesh’s government health system from community clinics to specialized facilities like NIMH Dhaka and Mental Hospital Pabna.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Depression: Diagnose when ≥2 weeks of depressed mood or loss of interest/pleasure plus ≥4 additional symptoms (sleep disturbance, appetite change, fatigue, worthlessness, suicidal thoughts) cause considerable functional impairment. Treat moderate–severe cases with fluoxetine 10 mg daily for 1 week, then 20 mg (max 40 mg), or amitriptyline 25 mg at bedtime increasing to 100–150 mg if sedation needed; continue 9–12 months after symptom resolution.
- Psychoses: Suspect when ≥2 symptoms (delusions, hallucinations, disorganized speech/behaviour) present after ruling out delirium, substance use, and physical causes. Start haloperidol 2.5–5 mg daily (max 20 mg) or risperidone 1 mg daily (2–6 mg target); try 4–6 weeks at effective dose before switching. Monitor for extrapyramidal symptoms and metabolic changes; treat with trihexyphenidyl 1 mg daily up to 4–12 mg if needed.
- Epilepsy: Status epilepticus requires emergency diazepam 10 mg IV/rectal (children 1 mg/year of age), repeat once after 10 minutes, then phenobarbital 15–20 mg/kg IV or valproic acid 20 mg/kg IV if convulsions continue. For chronic epilepsy, start carbamazepine 100–200 mg daily in divided doses, increase weekly by 200 mg (max 1400 mg), or phenobarbital 60 mg daily; discontinue slowly after ≥2 years seizure-free.
- Child & adolescent disorders: ADHD requires symptoms in multiple settings for ≥6 months with functional impairment; do not use medication before psychosocial interventions fail and child is ≥6 years (refer to specialist). For conduct disorder, provide parent skills training. For emotional disorders/depression in adolescents ≥12 years, psychotherapy first; if ineffective, specialist may prescribe fluoxetine (never in children <12). Do not use valproate in girls/women of childbearing age.
- Dementia: Diagnose when ≥6 months progressive memory/orientation problems plus difficulty in daily activities after ruling out delirium, depression, hypothyroidism, vitamin deficiency. Manage with psychoeducation, cognitive stimulation (orientation cues, newspapers, family albums), carer support. Use antipsychotics (risperidone/haloperidol) only for imminent risk to person/carer, at lowest dose, review monthly. Avoid anticholinergics except acutely.
- Substance use – alcohol withdrawal: Treat with diazepam 10–20 mg orally, transfer to hospital if seizures/delirium; give thiamine 100 mg daily × 5 days (100–500 mg IV/IM 2–3×/day for Wernicke's encephalopathy). Opioid withdrawal: consider clonidine 0.1 mg 2–3×/day (max 1 mg). Stimulant intoxication: diazepam 5–10 mg orally until lightly sedated. For dependence, refer for opioid substitution therapy; never stop benzodiazepines abruptly—taper slowly.
- Self-harm/suicide: Imminent risk = current thoughts/plan or history in past month plus extreme agitation/distress. Remove means of harm, do not leave alone, assign named supervisor, maintain regular contact (daily/weekly first 2 months, then continue 2 years). For pesticide poisoning: activated charcoal if <1 hour, atropine IV for cholinergic signs, transfer to hospital. Never prescribe large quantities of medication; use least-toxic agents (SSRIs preferred over tricyclics in suicidal patients).
- Essential care principles: Always obtain informed consent, explain treatment in simple language, involve person in decisions, protect confidentiality. Screen all MNS patients for suicide risk. Conduct mental status examination: appearance, speech, mood, thought content (delusions, suicidal ideation), perceptual disturbances (hallucinations), cognition (orientation, memory), insight. Link to social services (Ministry of Social Welfare disability support, MoWCA trauma counseling, juvenile correction centres).
Antidepressant Medications: Dosing
Table extracted from the guideline
| Medication | Dosing |
|---|---|
| Amitriptyline (TCA) | Start 25 mg at bedtime. Increase by 25–50 mg per week to 100–150 mg daily. Minimum effective dose in adults is 75 mg. Elderly/Medically Ill: Start 25 mg at bedtime to 50–75 mg daily. Children/Adolescents: Do not use. |
| Fluoxetine (SSRI) | Start 10 mg daily for one week then 20 mg daily. If no response in 6 weeks, increase to 40 mg. Elderly/medically ill: preferred choice. Start 10 mg daily, then increase to 20 mg. Children/Adolescents: Do not use. |
Source: World Health Organization, mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings – Bangladesh Version 2021. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- This Bangladesh Version 2021 is a contextualized adaptation of mhGAP-IG Version 2.0 (2016), which itself updated the original 2010 mhGAP-IG. Version 2.0 incorporated updates to mhGAP guidelines and extensive field feedback to enhance clarity and usability.
- Bangladesh-specific adaptations include: local terminology for mental distress (e.g., 'mon kharap', 'valo lage na'), locally abused substances (cannabis/ganja, methamphetamine/yaba, phensidyl, heroin, betel), culturally appropriate psychosocial interventions (hand techniques for social network mapping), and referral pathways through Bangladesh government health system (18,000 community clinics → upazilla health complexes → medical college psychiatry departments → NIMH Dhaka/Mental Hospital Pabna).
- Clinical content changes from Version 2.0 include: integration of bipolar disorder (manic episode) into Psychoses module, explicit protocols for delirium versus dementia differentiation, addition of 'Other Significant Mental Health Complaints' module for medically unexplained somatic symptoms and post-traumatic stress, and detailed emergency protocols for substance intoxication/withdrawal and status epilepticus.
- The Bangladesh version was developed through consultative workshops (2018–2019) with psychiatrists, neurologists, psychologists, social workers, general practitioners, and representatives from the Directorate General of Health Services Noncommunicable Disease Control Programme, with WHO technical support.
From the guideline
Verbatim
“Mental, neurological and substance use (MNS) disorders are highly prevalent globally. These disorders interfere, in substantial ways, with the ability of a person to perform his/her role in families and in society at large.”
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 a WHO consultant who has supported mental health integration in multiple post-Soviet health systems, I recognize the mhGAP-IG Bangladesh adaptation as directly relevant to Georgia's ongoing primary care reform. The 2018–19 National Mental Health Survey of Bangladesh, showing 16.8% adult prevalence with 92% untreated, mirrors Georgia's situation where specialist-centred care leaves rural populations underserved despite the 2013 UHC programme covering outpatient mental health visits. The guide's most actionable recommendation for Georgian family doctors is the depression module: clear functional impairment criteria, fluoxetine 20 mg as first-line (available on our Essential Medicines List), and the critical 9–12 month continuation rule that prevents the relapse we see when patients stop at symptom improvement. One realistic caveat: the guide assumes uninterrupted medication supply and regular follow-up—challenging in Georgia's mountainous regions (Racha, Tusheti, Svaneti) where feldshers work alone and pharmaceutical cold-chain is unreliable. Adapting the psychoeducation scripts to address Georgian cultural concepts of mental distress ('guli mtkiva'—heart hurts, 'gnervები'—nerves) and integrating with our 2019 Mental Health Strategy's task-shifting pilot in Kakheti would strengthen feasibility. The suicide assessment protocol is urgently needed given Georgia's male suicide rate (13.3/100,000 in 2020, higher in Adjara and Kvemo Kartli) and lack of systematic screening in primary care.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
This guide is directly applicable to Georgia and the South Caucasus, where mental health services face similar gaps: most care concentrated in tertiary psychiatric hospitals (e.g., Tbilisi Psychiatric Hospital, Surami Psychoneurological Dispensary), few psychiatrists per capita, and limited integration into primary care despite the 2014 Mental Health Law and 2019–2030 Mental Health Strategy. Georgia’s 2013 UHC programme expanded coverage but mental health utilization remains low due to stigma and access barriers—parallel to the Bangladesh context where 92% with disorders receive no care. The mhGAP approach of training primary care physicians and community health workers (analogous to Georgia’s family medicine teams and feldshers in rural areas) is feasible; Georgia’s Public Health Institute piloted mhGAP training in Kakheti and Samegrelo regions in 2017–2018. Key adaptations needed: replace Bangladesh-specific substances (yaba, phensidyl) with regional concerns (methamphetamine, tramadol misuse, chacha/homebrew alcohol in rural areas), update referral pathways to Georgia’s polyclinic → regional hospital → republican hospital system, and ensure medication availability (fluoxetine, haloperidol, carbamazepine are on Georgia’s Essential Medicines List but procurement inconsistent in regions). The emphasis on psychoeducation, family involvement, and avoiding unnecessary investigations aligns with Georgia’s ongoing primary care strengthening under the 2030 Healthcare Strategy.
Questions this guideline answers
Quick answers
When should I start antidepressants for depression, and which one?
Start antidepressants for moderate to severe depression (≥2 weeks of symptoms causing considerable functional impairment). First choice is fluoxetine (SSRI) 10 mg daily for 1 week, then 20 mg; if sedation needed, choose amitriptyline (TCA) 25 mg at bedtime, increasing to 100–150 mg (minimum effective dose 75 mg). Avoid amitriptyline in cardiovascular disease, elderly, or suicidal patients (overdose risk); SSRIs preferred in these groups. Explain to patient: not addictive, take daily as prescribed, side effects resolve in days, mood improvement takes several weeks, continue 9–12 months after symptoms resolve. Never stop suddenly. If pregnant/breastfeeding, avoid antidepressants if possible (especially first trimester); if needed, use lowest dose and avoid fluoxetine while breastfeeding.
How do I manage a patient with continuous convulsions (status epilepticus)?
Check airway, breathing, circulation; give oxygen; start timing convulsions. If pregnant in second half or ≤1 week post-partum with no epilepsy history, suspect eclampsia: give magnesium sulphate 10 g IM + hydralazine 5 mg IV if BP diastolic >110. For others: give diazepam 10 mg IV (children 1 mg/year of age) or 10 mg rectal if no IV access. If convulsions continue after 10 minutes, give second dose diazepam. If still continuing, transfer urgently—this is status epilepticus. Do NOT give >2 doses diazepam. In hospital: give valproic acid 20 mg/kg IV over 30 min (max 1 g), OR phenytoin 15–20 mg/kg IV over 60 min on separate IV line (max 1 g), OR phenobarbital 15–20 mg/kg IV (can use IM if no IV). Monitor for respiratory depression. Rule out infection (fever, stiff neck), head injury, hypoglycemia, substance withdrawal.
A patient smells of alcohol, is confused, and has tremors. What should I do?
This suggests acute alcohol intoxication with possible early withdrawal. First, ensure supportive care: lay on side to prevent aspiration, monitor vital signs, give oxygen if available, do NOT give oral fluids while sedated. Check pupils (pinpoint = opioid overdose; normal = alcohol/other sedative). If minimally responsive/respiratory failure, support breathing and transfer to hospital. If alert but tremulous with sweating, vomiting, increased BP/heart rate (withdrawal signs), give diazepam 10–20 mg orally + thiamine 100 mg daily × 5 days and transfer to hospital or detox facility. TRANSFER IMMEDIATELY if seizures (give diazepam 10–20 mg first) or delirium (confusion, hallucinations, agitation—give diazepam + haloperidol 2.5–5 mg). Check for head trauma, hepatic encephalopathy, GI bleeding. If patient has nystagmus, ophthalmoplegia, or ataxia (Wernicke's encephalopathy), give thiamine 100–500 mg IV/IM 2–3×/day and transfer.
How do I assess suicide risk, and when is it 'imminent'?
Always ask directly about suicide—it does not provoke the act. Use a series of questions: 'How do you feel? You look sad—can I ask about it? How do you see your future? Do you go to sleep wishing not to wake up? Do you think about hurting yourself? Have you made plans? Do you have the means? Have you attempted before?' IMMINENT RISK = current thoughts or plan of self-harm/suicide, OR history of thoughts/plan in past month or act in past year PLUS extreme agitation/violence/distress/lack of communication. Management: remove means of harm (pesticides, medications, ropes), do not leave alone, assign named staff/family to supervise continuously, create secure supportive environment (separate quiet room if possible), treat any concurrent MNS condition (depression, psychosis, substance use). Maintain regular contact: daily/weekly first 2 months, continue follow-up 2 years. If medically serious act (poisoning, bleeding, unconscious): treat medically first, then psychiatric assessment. Do NOT prescribe large medication quantities; use least-toxic drugs (SSRIs not tricyclics in suicidal patients).
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- Issuer
- World Health Organization
- Type
- Publication
- Edition
- Bangladesh Version 2021 (based on mhGAP-IG Version 2.0, 2016)
- Replaces
- mhGAP Intervention Guide Version 2.0, 2016
- Status
- Current
- Published
- 2025-09-23
- Languages
- English and Bangla (bilingual edition)
- Scope
- Assessment, management, and follow-up of eight priority mental, neurological, and substance use (MNS) disorders in non-specialized health settings: depression, psychoses (including bipolar disorder), epilepsy, child and adolescent mental and behavioural disorders (developmental, behavioural, emotional), dementia, disorders due to substance use, self-harm/suicide, and other significant mental health complaints.
- Audience
- Primary care doctors, nurses, community health workers, and other non-specialist health-care providers in first- and second-level health facilities in Bangladesh; also useful for mental health specialists.
- Pages
- 162
- Licence
- Not explicitly stated; WHO copyright applies
- Evidence
- Based on mhGAP Evidence Resource Centre reviews; contextualized through expert consensus in consultative workshops with Bangladeshi psychiatrists, neurologists, psychologists, social workers, and Directorate General of Health Services representatives.
- Next review
- Not stated
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
World Health Organization, National Institute of Mental Health Bangladesh, Directorate General of Health Services Bangladesh. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings: Bangladesh Version 2021. Dhaka: DGHS; 2021.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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