Supplementary appendix

This appendix formed part of the original submission and has been peer reviewed.
We post it as supplied by the authors.

Supplement to: Brohan E, Chowdhary N, Dua T, et al. The WHO Mental Health Gap
Action Programme for mental, neurological, and substance use conditions: the new
and updated guideline recommendations. Lancet Psychiatry 2023; published online
Nov 16. https://doi.org/10.1016/S2215-0366(23)00370-X.
Appendix
WHO guideline steering group p2
Table 1. Summary of recommenda�ons pp 3–14

1
WHO guideline steering group
WHO Department of Mental Health and Substance Use: Ken Carswell, Sudipto Chaterjee, Batool Fa�ma, Alexandra Fleischmann, Brandon
Gray, Charlote Hanlon, Fahmy Hanna, Dzmitry Krupchanka, Aiysha Malik, Mark van Ommeren, Vladimir Poznyak, Katrin Seeher, Chiara Servili,
Inka Weissbecker.
WHO regional offices: Florence Baingana (Regional Office for Africa), Luis Alfonzo Bello (Regional Office for the Americas, also know as the Pan
American Health Organiza�on [PAHO]), Andrea Bruni (Regional Office for South-East Asia), Ana Carina Jorge Dos Santos Ferreira Borges Bigot
(PAHO), Chencho Dorji (Regional Office for South-East Asia), Mar�n Vandendyck (Regional Office for the Western Pacific), Ledia Lazeri (Regional
Office for Europe), Maristela Goldnadel Monteiro (PAHO), Manju Rani (Regional Office for South-East Asia), Khalid Saeed (Regional Office for the
Eastern Mediterranean), Renato Oliveira e Souza (PAHO).
Other departments at WHO headquarters: Wole Ameyan (Department of Global HIV, Hepa��s, STI programme), Valen�na Baltag (Department
of Maternal, Newborn, Child and Adolescent Health and Ageing), Francesco Branca (Department of Nutri�on and Food Safety), Bernadete
Cappello (Health Product Policy and Standards Department), Giorgio Cometo (Health Workforce Department), Suraya Dalil (WHO Special
Programme on Primary Health Care), Albis Gabrielli (Department of Neglected Tropical Diseases), Benedikt Hutner (Health Product Policy and
Standards Department), Ernesto Jaramillo (WHO Global TB Programme), Taskeen Khan (Department of Noncommunicable Diseases), Jonathan
King (Department of Neglected Tropical Diseases), Ruediger Krech (Department of Health Promo�on), Nathalie Roebbel (Department of Social
Determinants of Health), Nhan Tran (Department of Social Determinants of Health), Yuka Sumi (Department of Maternal, Newborn, Child and
Adolescent Health and Ageing), Shams Syed (Special Programme on Primary Health Care).

2
Table 1. Summary of recommenda�ons

Strength of recommenda�on
Alcohol use disorders (ALC)
ALC1 ALC1 (update): Baclofen should be considered for treatment of adults with alcohol dependence post- Condi�onal
detoxifica�on.
ALC2 ALC2 (update): Structured and standardized psychosocial interven�ons should be considered for the Condi�onal
treatment of alcohol dependence.
ALC3 ALC3 (new): Digitally delivered interven�ons should be considered for adults with alcohol use Condi�onal
disorders or with hazardous alcohol use. They should not replace provision of other forms of
interven�ons and should ensure free and informed consent, safety, confiden�ality, privacy and
security.
ALC4 ALC4 (new): Combined psychosocial and pharmacological interven�ons should be offered for adults Strong
with alcohol dependence.
Anxiety (ANX)
ANX1 ANX1 (new): Selec�ve serotonin reuptake inhibitors (SSRIs) should be considered for adults with Condi�onal
panic disorder. If SSRIs are not available, consider offering tricyclic an�depressants (TCAs). SSRIs
should be considered for adults with generalized anxiety disorder (GAD).
ANX2 ANX2 (new): Brief, structured psychological interven�ons based on principles of cogni�ve Strong
behavioural therapy (CBT) should be offered for adults with GAD and/or panic disorder.
ANX3 ANX3 (new): When brief, structured psychological interven�ons based on principles of CBT are Condi�onal
offered for adults with GAD and/or panic disorder, different delivery formats should be considered
based on available resources as well as individual preferences, including:
• Individual and/or group face-to-face;

3
 • Digital/online and/or face-to-face;
• Guided and/or unguided self-help;
• Specialist and/or non-specialist.
ANX4 ANX4 (new): Stress management techniques, namely relaxa�on and/or mindfulness training, should Condi�onal
be considered for adults with GAD and/or panic disorder.
ANX5 ANX5 (new): Structured physical exercise should be considered for adults with GAD and/or panic Condi�onal
disorder.
ANX6 ANX6 (new): Benzodiazepines are not recommended for the treatment of adults with GAD and/or Strong
panic disorder. For emergency management of acute and severe anxiety symptoms, benzodiazepines
may be considered, but only as a short-term (3–7 days maximum) measure.
ANX7 ANX7 (new): Collaborative care (CC) should be considered for adults with depression and/or anxiety Condi�onal
and physical health condi�ons.
Child and adolescent mental disorders (CAMH)
CAMH1 CAMH1 (update): For children 6 years old and above and adolescents who have an aten�on deficit Condi�onal
hyperac�vity disorder (ADHD) diagnosis, methylphenidate may be considered provided that:
• ADHD symptoms are still causing persistent significant impairment in at least one domain of
functioning (education, interpersonal relationships, occupation), after the implementation
of environmental modifications in schools, at home or in other relevant settings;
• A careful assessment of the child/adolescent has been conducted;
• The child/adolescent and the caregivers, as appropriate, have been informed about ADHD
treatment options and supported in supported decision-making;
• Methylphenidate prescription is made by, or in consultation with, a specialist.
CAMH2 CAMH2.1 (new): Universally delivered psychosocial interven�ons that use curriculum-based, family- Condi�onal
based, exercise-based methods and/or social and personal skills development to improve emo�onal

4
 regula�on should be considered for promo�on of psychosocial well-being in children.

CAMH2.2 (new): Psychosocial interven�ons that include cogni�ve behavioural therapy (CBT), Strong
psychoeduca�on and family-focused treatment approaches should be offered to children whose
parents have mental health condi�ons for the preven�on of depression and anxiety.
CAMH3 CAMH3.1 (new): Psychosocial interven�ons focused on social skills training and developmental Strong
behavioural approaches should be offered to improve development, well-being and func�oning in
children and adolescents with au�sm.
CAMH3.2 (new): Cogni�ve behavioural therapy (CBT) should be offered to children and adolescents Strong
with au�sm with anxiety.
CAMH3.3 (new): Psychosocial interven�ons focused on social skills, cogni�ve and organiza�onal Condi�onal (social skills training,
skills training should be considered to improve development and func�oning in children and cogni�ve interven�ons) and Strong
adolescents with ADHD. (organiza�onal skills training)
CAMH3.4 (new): Beginning-to-read interven�ons should be offered to improve communica�on and Strong
academic performance in children with disorders of intellectual development.
CAMH3.5 (new): Early communica�on interven�ons involving direct instruc�on approaches should Condi�onal
be considered for improving expressive phonological skills and reducing stutering for children with
developmental speech disorders.
CAMH3.6 (new): Psychosocial interven�ons using cogni�ve learning techniques to enhance Condi�onal
communica�on and social competencies should be considered for children and adolescents with
neurodevelopmental disabili�es.
CAMH3.7 (new): Structured physical exercise should be considered to improve development, Condi�onal
including social and communica�on and func�oning in children and adolescents with au�sm.
CAMH3.8 (new): Structured physical exercise should be considered to improve motor skills and Condi�onal
func�oning, including aten�on and execu�ve func�oning, and reduce anxiety and problem

5
 behaviours in children and adolescents with ADHD.

CAMH3.9 (new): Specialized instruc�onal techniques should be considered to improve academic Condi�onal
performance, including wri�ng skills, reading comprehension and maths in children and adolescents
with developmental learning disorders.
CAMH3.10 (new): Task-oriented instruc�on should be considered to improve motor skills and task Condi�onal
performance in children with developmental coordina�on disorders.
CAMH3.11 (new): Structured physical exercise and ac�vity should be offered to improve Strong
development outcomes, including motor skills and func�oning, in children and adolescents with
cerebral palsy.
CAMH4 CAMH4.1 (new): Pharmacological interven�ons are not recommended in children and adolescents Strong
with anxiety disorders.
CAMH4.2 (new): An�depressant medicines (ADMs) are not recommended for the treatment of Strong
children 12 years of age and below with depressive episode/disorder.
CAMH4.3 (new): If psychosocial interven�ons alone prove ineffec�ve in adolescents (13–17 years) Strong
with moderate-to-severe depression, referral to or consulta�on with a specialist to undertake a more
comprehensive assessment and to explore ini�a�on of fluoxe�ne in combina�on with psychological
treatments should be offered.
Condi�ons related to stress (STR)

STR1 STR1 (update): Psychological interven�ons should be considered for adults with post-trauma�c stress Condi�onal
disorder (PTSD). Namely, these include:
• Individual face-to-face cognitive behavioural therapy (CBT) with a trauma focus;
• Group face-to-face CBT with a trauma focus;
• Digital/remote CBT with a trauma focus;
• Eye movement desensitization and reprocessing (EMDR);

6
 • Stress management.

STR2 STR2 (update): Psychological interven�ons should be offered for children and adolescents with PTSD. Strong
Namely, these include:
• Individual face-to-face CBT with a trauma focus;
• Group face-to-face CBT with a trauma focus;
• EMDR.
Demen�a (DEM)
DEM1 DEM1.1 (update): Psychosocial interven�ons – namely mindfulness-based interven�ons, Strong
mul�component interven�ons, psychoeduca�on and psychotherapy/counselling – should be offered
for carers of people living with demen�a.
DEM1.2 (update): Respite care should be considered for carers of people living with demen�a. Condi�onal
DEM1.3 (update): Depression and anxiety in carers of people living with demen�a should be Strong
assessed and treated in line with mhGAP recommenda�ons for depression and anxiety.
DEM2 DEM2: There was insufficient evidence to update the recommendation, so the current recommendation
is validated.

Psychological interven�ons – namely cogni�ve behavioural therapy (CBT), interpersonal therapy Condi�onal
(IPT), structured counselling and behavioural ac�va�on therapy (BAT) – should be considered for
people with demen�a and mild-to-moderate depression.
DEM3 DEM3.1 (update): Physical ac�vity interven�ons – namely physical exercise delivered 3–4 �mes per Strong
week for 30–45 minutes for more than 12 weeks – should be offered to people living with demen�a.
DEM3.2 (update): Nonpharmacological interven�ons – namely CBT, cogni�ve s�mula�on therapy Condi�onal
and cogni�ve training (in alphabe�cal order) – should be considered for people with demen�a.
Depression (DEP)

7
DEP1 DEP1 (update): In adults with moderate-to-severe depression, citalopram, escitalopram, fluoxe�ne, Condi�onal
fluvoxamine, paroxe�ne or sertraline (SSRIs) or amitriptyline (TCA) should be considered.
DEP2 DEP2 (update): In adults with moderate-to-severe depression who have benefited from ini�al Condi�onal
an�depressant treatment, con�nua�on of the an�depressant treatment should be considered for at
least six months a�er remission. Treatment should be regularly monitored, with special aten�on to
treatment adherence, change in depressive symptoms and possible adverse effects.
DEP3 DEP3 (update): Structured psychological interven�ons should be offered for the treatment of adults Strong
with moderate-to-severe depression, namely behavioural ac�va�on therapy (BAT); brief
psychodynamic therapy; cogni�ve behavioural therapy (CBT); interpersonal therapy (IPT); problem-
solving therapy (PST); and third wave therapies (3WV).
DEP4 DEP4 (update): In adults with moderate-to-severe depression, psychological interven�ons or Condi�onal
combined treatment should be considered based on individual preferences and careful considera�on
of the balance of benefits and harms. An�depressant medicine (ADM) alone for adults with
depression (moderate to severe) should only be considered when psychological interven�ons are not
available. Providers should keep in mind the possible adverse effects associated with ADM, as well as
individual preferences.
Drug use disorders (DRU)

DRU1 DRU1.1 (update): Adults using cannabis should be offered screening and brief interven�on. Brief Strong
interven�on should comprise at least a single session, incorpora�ng individualized feedback and
advice on reducing or stopping cannabis consump�on, and the offer to follow-up.
DRU1.2 (update): Adults using psychos�mulants should be offered screening and brief interven�on. Strong
Brief interven�on should comprise at least a single session, incorpora�ng individualized feedback
and advice on reducing or stopping psychos�mulant consump�on, and the offer to follow-up.
DRU1.3 (update): For adults with hazardous cannabis or psychos�mulant use, or with disorders due Condi�onal

8
 to use of these substances who do not respond to brief interven�ons, referral for specialist
interven�on should be considered.
DRU2 DRU2 (update): Dexamphetamine, methylphenidate and modafinil are not recommended for the Condi�onal
treatment of cocaine or s�mulant use disorders due to safety concerns.
DRU3 DRU3 (update): Psychosocial interven�ons – namely cogni�ve behavioural therapy (CBT) and Strong
con�ngency management (CM) – should be offered to adults with cocaine and s�mulant
dependence.
DRU4 DRU4 (new): Digitally delivered interven�ons should be considered for adults using drugs or with Condi�onal
drug use disorders. They should not replace provision of other forms of interven�ons and should
ensure pa�ent’s informed consent, safety, confiden�ality, privacy and security.
DRU5 DRU5 (new): Recovery-oriented services on a voluntary basis should be considered for adults with Condi�onal
drug dependence. Namely, case management, long-term residen�al and con�nuing community care
approaches, occupa�on-based therapies and peer support groups should be considered for recovery
management of people with drug dependence.
Epilepsy and seizures (EPI)

EPI1 EPI1 (update): In adults with established status epilep�cus, i.e. seizures persis�ng a�er two doses of Condi�onal
benzodiazepines, either intravenous fosphenytoin, intravenous phenytoin, intravenous
leve�racetam, intravenous phenobarbital or intravenous valproic acid (sodium valproate) should be
considered with appropriate monitoring. The choice of these medicines depends on local resource
se�ngs, including availability and facili�es for monitoring.
EPI2 EPI2 (update): In children with established status epilep�cus, i.e. seizures persis�ng a�er two doses Condi�onal
of benzodiazepines, intravenous fosphenytoin, intravenous phenytoin, intravenous leve�racetam,
intravenous phenobarbital or intravenous valproic acid (sodium valproate), should be considered
with appropriate monitoring. The choice of these medicines depends on local resources, including

9
 availability and facili�es for monitoring.

EPI3 EPI3.1 (update): Generalized onset seizures: Strong

Monotherapy with lamotrigine or leve�racetam, or valproic acid (sodium valproate), should be
offered as first-line treatment for generalized onset seizures in men/boys and women/girls who are
not of childbearing poten�al.
In women and girls of childbearing poten�al with generalized onset seizures, lamotrigine or
leve�racetam should be offered as first-line monotherapy.
If the first monotherapy is not successful for generalized onset seizures, an alterna�ve first-line
monotherapy should be tried.
Valproic acid (sodium valproate) is not recommended in women and girls of childbearing poten�al
owing to the high risk of birth defects and neurodevelopmental disorders in children exposed to
valproic acid (sodium valproate) in the womb.
If lamotrigine, leve�racetam and valproic acid (sodium valproate) are not available for generalized
onset seizures, monotherapy with either phenytoin or phenobarbital can be considered.
EPI3.2 (update): Focal onset seizures: Strong
Monotherapy with lamotrigine or leve�racetam should be offered as first-line treatment for focal
onset seizures in children and adults with epilepsy.
If neither lamotrigine nor leve�racetam are available, then carbamazepine should be used as an
alternate first-line treatment for focal onset seizures in children and adults with epilepsy.
If the first monotherapy is not successful for focal onset seizures, an alterna�ve first-line
monotherapy should be tried.
Lacosamide should be offered as a second-line monotherapy for focal onset seizures if none of the
first-line medicines are effec�ve.
If an�seizure medicine monotherapy is unsuccessful in people with generalized onset seizures or

10
 focal onset seizures, prompt referral should be made to a specialist for considera�on of other
treatment op�ons.
EPI4 EPI4.1 (update): In women and girls with epilepsy who are of childbearing poten�al, lamotrigine or Strong
leve�racetam should be offered as first-line monotherapy for both generalized onset seizures and
focal onset seizures.

Women with epilepsy should have seizures controlled as well as possible with the minimum dose of
an�seizure medica�ons (ASMs) taken in monotherapy, wherever possible.

Valproic acid (sodium valproate) is not recommended in women and girls of childbearing poten�al
because of poten�al harm to the fetus.
EPI4.2 (update): Standard breas�eeding recommenda�ons remain appropriate for women with Strong
epilepsy taking the ASMs included in this review (phenobarbital, phenytoin, valproic acid (sodium
valproate), carbamazepine, lamotrigine, leve�racetam, topiramate, lacosamide).
EPI5 EPI5 (new): Nocturnal supervision should be considered for preven�on of sudden unexpected death Condi�onal
in epilepsy (SUDEP).
Overarching areas (OVE)

OVE1 OVE1 (new): Psychosocial interven�ons – namely psychoeduca�on using problem-solving and Condi�onal
cogni�ve-behavioural approaches (either individual or family-based), self-help interven�ons and
mutual support groups – should be considered for carers of persons with psychosis or bipolar
disorder.
Psychosis and bipolar disorder (PSY)

11
PSY1 PSY1.1 (update): Oral an�psycho�c medicines – namely aripiprazole, chlorpromazine, haloperidol, Strong
olanzapine, paliperidone, que�apine, risperidone – should be offered for adults with a psycho�c
disorder (including schizophrenia), carefully balancing effec�veness, side-effects and individual
preference.
PSY1.2 (update): Clozapine should be considered for adults with a treatment-resistant psycho�c Condi�onal
disorder (including schizophrenia) under mental health specialist supervision, carefully balancing
effec�veness, side-effects and individual preference.
PSY2 PSY2 (update): Maintenance therapy with an�psycho�c medicine for a minimum of 7–12 months Strong
should be offered in adults with a first episode of psychosis (including schizophrenia) in remission,
carefully balancing effec�veness, side-effects and individual preference.
PSY3 PSY3 (update): Maintenance therapy with mood stabilizers or an�psycho�c medicines should be Condi�onal
considered for at least six months for adults with bipolar disorder in remission, carefully balancing
effec�veness, side-effects and individual preference.
PSY4 PSY4 (update): Long-ac�ng injec�on (LAI) an�psycho�c medicines – namely fluphenazine, Condi�onal
haloperidol, paliperidone, risperidone and zuclopenthixol – should be considered as an alterna�ve to
oral an�psycho�c medicines for adults with psycho�c disorders (including schizophrenia) requiring
long-term treatment, carefully balancing effec�veness, side-effects and individual preference.
PSY5 PSY5.1 (update): Oral an�psycho�c medicines – namely aripiprazole, olanzapine, paliperidone, Condi�onal
que�apine, risperidone – should be considered under specialist supervision for adolescents with
psycho�c disorders (including schizophrenia), carefully balancing effec�veness, side-effects and
individual preference.
PSY5.2 (update): Clozapine should be considered for adolescents with a treatment-resistant Condi�onal
psycho�c disorder (including schizophrenia) under specialist supervision, carefully balancing
effec�veness, side-effects and individual preference.

12
PSY6 PSY6 (update): Psychotropic medicines (an�psycho�c medicines, namely aripiprazole, olanzapine, Condi�onal
que�apine, risperidone, and mood stabilizers, namely lithium) should be considered under specialist
supervision for adolescents with bipolar disorder (current episode manic), carefully balancing
effec�veness, side-effects and individual preference.
PSY7 PSY7.1 (update): Oral an�psycho�c medicines – namely aripiprazole, haloperidol, olanzapine, Strong
paliperidone or que�apine – or mood stabilizers – namely carbamazepine, lithium, valproic acid
(sodium valproate) – should be offered to adults with bipolar disorder (current episode mania),
carefully balancing effec�veness, side-effects and individual preference.
PSY7.2 (update): Valproic acid (sodium valproate) should not be used in women and girls of Strong
childbearing poten�al owing to the high risk of birth defects and neurodevelopmental disorders in
children in utero.
PSY8 PSY8.1 (update): Mood stabilizers – namely carbamazepine, lithium, valproic acid (sodium valproate) Condi�onal
– or oral an�psycho�c medicines – namely aripiprazole, olanzapine, que�apine – should be
considered for maintenance treatment for adults with bipolar disorder in remission, carefully
balancing effec�veness, side-effects and individual preference.
PSY8.2 (update): Valproic acid (sodium valproate) should not be used in women and girls of Strong
childbearing poten�al with bipolar disorder in remission owing to the high risk of birth defects and
neurodevelopmental disorders in children in utero.
PSY9 PSY9 (update): Fluoxe�ne, olanzapine, que�apine, valproic acid (sodium valproate) or venlafaxine Condi�onal
should be considered for adults with bipolar depression. If fluoxe�ne or venlafaxine are chosen, they
should be co-administered with a mood stabilizer (namely que�apine, olanzapine, carbamazepine,
valproic acid [sodium valproate], lithium).
PSY10 PSY10 (update): Treatment based on cogni�ve behavioural therapy (CBT) should be considered for Condi�onal
adults with psycho�c disorders (including schizophrenia) in the acute phase of the condi�on where

13
 sufficient specialist support is available.

PSY11 PSY11 (update): Psychosocial interven�ons – namely family interven�ons, family psychoeduca�on, Strong
psychoeduca�on and CBT – either alone or in combina�on should be offered to adults with psychosis
(including schizophrenia) during the maintenance phase.
PSY12 PSY12 (update): Individual psychological interven�ons – namely CBT, family psychoeduca�on, Condi�onal
medicine adherence therapy, online psychoeduca�on or psychoeduca�on – should be considered as
adjunc�ve to pharmacological interven�ons in the treatment of adults with bipolar disorder in
remission.
Self-harm and suicide (SUI)
SUI1 SUI1 (new): Safety planning type-interven�ons, i.e. interven�ons based on principles of safety Condi�onal
planning which are mul�component or supplemented with follow-up or support, can be considered.

SUI2 SUI2: The evidence regarding effec�veness of stand-alone media campaigns (to raise awareness and
sensi�ze the general public about suicide and its preven�on) in reducing deaths from suicide, suicide
atempts and acts of self-harm is insufficient to make a recommendation.
SUI3 SUI3 (new): Stand-alone digital interven�ons based on evidence-based interven�ons such as Condi�onal
cogni�ve behavioural therapy (CBT), dialec�cal behaviour therapy, problem-solving therapy (PST)
and mindfulness should be considered as support for persons with suicidal thoughts.

14