The following text provides the scoping questions used, the recommendations agreed after examination of the evidence, including evidence on harms, benefits, values, preferences, cost-effectiveness and feasibility, and qualifying remarks. For full details of the evidence used and the decision-making process, please consult the evidence profile for each numbered recommendation provided in Annex 5.
Acute traumatic stress symptoms after a potentially traumatic recent event (recommendations 1–4)
Acute traumatic stress symptoms refer to symptoms of intrusion, avoidance and hyperarousal – associated with significant impairment in daily functioning – in the first month after a potentially traumatic event. Other symptoms of acute stress, including hyperventilation, conversion and dissociative symptoms, and secondary non-organic nocturnal enuresis in children, are dealt with in other recommendations in these guidelines.
Psychological interventions and pharmacological treatments, especially benzodiazepines, have been used to manage people suffering symptoms of acute distress. There is currently no consensus on the effectiveness of such management. The GDG examined the evidence on use of early psychological and pharmacological interventions in adults and in children and adolescents with symptoms of acute traumatic stress syndrome, and made the following recommendations.
1. Acute traumatic stress symptoms (first month): early psychological interventions – adults
Scoping question 1: For adults with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in a reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 1
Cognitive-behavioural therapy (CBT) with a trauma focus should be considered in adults with acute traumatic stress symptoms associated with significant impairment in daily functioning.
Strength of recommendation: standard
Quality of evidence: moderate
On the basis of available evidence, no specific recommendation can be made about stand-alone problem-solving counselling, eye movement desensitization and reprocessing (EMDR), relaxation or psycho-education for adults with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event.
Strength of recommendation: not applicable
Quality of evidence: very low
Remarks
CBT with a trauma focus should only be offered in those contexts where individuals are competent (trained and supervised) to provide the therapy.
There is already a
WHO (2010)
mhGAP recommendation to offer access to psychological first aid to people who have been recently exposed to potentially traumatic events. When combined, these recommendations imply that psychological first aid should be considered in all adults with acute traumatic stress symptoms; and, where competent staff are available, CBT with a trauma focus should be considered in adults with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event. In situations without sufficient resources to provide CBT with a trauma focus, other interventions such as stress management may be considered in addition to psychological first aid.
2. Acute traumatic stress symptoms (first month): early psychological interventions – children and adolescents
Scoping question 2: For children and adolescents with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in a reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 2
On the basis of available evidence, no specific recommendation can be made on early psychological interventions (covering problem-solving counseling, relaxation, psycho-education, eye movement desensitization and reprocessing (EMDR) and cognitive-behavioural therapy (CBT)) for children and adolescents with acute traumatic stress symptoms associated with significant impairment in daily functioning.
Strength of recommendation: not applicable
Quality of evidence: very low
Remarks
There is already a
WHO (2010)
mhGAP recommendation to offer access to psychological first aid to people who have been recently exposed to potentially traumatic events. Therefore, as no further specific recommendation can be made, psychological first aid should be considered in children and adolescents with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event.
3. Acute traumatic stress symptoms (first month): pharmacological interventions – adults
Scoping question 3: For adults with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event, do pharmacological interventions (benzodiazepines and antidepressants), when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 3
Benzodiazepines and antidepressants should not be offered to adults to reduce acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event.
For benzodiazepines:
Strength of recommendation: strong
Quality of evidence: very low
For antidepressants:
Strength of recommendation: standard
Quality of evidence: very low
Remarks
Clinicians should rule out concurrent disorders that may warrant treatment with benzodiazepines and antidepressants.
There is already a
WHO (2010)
mhGAP recommendation to offer access to psychological first aid to people who have been recently exposed to potentially traumatic events. In addition, recommendation 1(i) (on psychological interventions for acute traumatic stress symptoms in adults) is that “cognitive-behavioural therapy (CBT) with a trauma focus should be considered in adults with acute traumatic stress symptoms associated with significant impairment in daily functioning”. When combined, these recommendations imply that psychological first aid and (where resources exist) CBT should be considered in adults with acute traumatic stress symptoms associated with impairment in daily functioning in the first month after a potentially traumatic event.
4. Acute traumatic stress symptoms (first month): pharmacological interventions – children and adolescents
Scoping question 4: For children and adolescents with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event, do pharmacological interventions (benzodiazepines and antidepressants), when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 4
Benzodiazepines and antidepressants should not be offered to reduce acute traumatic stress symptoms associated with significant impairment in daily functioning in children and adolescents.
Strength of recommendation: strong
Quality of evidence: very low
Remarks
There is already a
WHO (2010)
mhGAP recommendation to offer access to psychological first aid to people who have been recently exposed to potentially traumatic events. Therefore, as no further specific recommendation can be made, psychological first aid should be considered in children and adolescents with acute traumatic stress symptoms associated with significant impairment in daily functioning in the first month after a potentially traumatic event.
Insomnia after a potentially traumatic recent event (recommendations 5–8)
Exposure to potentially traumatic events is common, and symptoms of acute stress in the aftermath of such events are frequently reported. Insomnia is a commonly reported symptom of acute stress. The GDG considered the evidence and made the following recommendations on psychological and pharmacological interventions for children and adults with insomnia after a potentially traumatic recent event.
5. Acute (secondary) insomnia (first month): early psychological interventions – adults
Scoping question 5: For adults with acute (secondary) insomnia in the first month after a potentially traumatic event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 5
Relaxation techniques (e.g. progressive muscle relaxation or cultural equivalents) and advice about sleep hygiene (including advice about psychostimulants, such as coffee, nicotine and alcohol) should be considered for adults with acute (secondary) insomnia in the first month after exposure to a potentially traumatic event.
Strength of recommendation: standard
Quality of evidence: very low
Remarks
In many settings, relaxation may be made available through existing cultural practices.
It is important always to assess for and manage other possible physical causes for insomnia, even when the insomnia starts within one month of a potentially traumatic event. Where possible, environmental causes for insomnia (e.g. noisy environments) should be addressed.
Health-care providers should explain that insomnia is common after recent exposure to extreme stressors. If insomnia persists for more than one month, the person should be reassessed for other conditions that may need treatment, including anxiety disorders (PTSD, generalized anxiety disorder, panic disorder), depressive disorder and, in adolescents, alcohol or drug use disorder.
There is already a
WHO (2010)
mhGAP recommendation to offer access to psychological first aid to people who have been recently exposed to potentially traumatic events. When combined, these recommendations imply that psychological first aid, relaxation techniques and advice about sleep hygiene should be considered in adults with acute (secondary) insomnia in the first month after a potentially traumatic event.
6. Acute (secondary) insomnia (first month): early psychological interventions – children and adolescents
Scoping question 6: For children and adolescents with acute (secondary) insomnia in the first month after a potentially traumatic event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 6
On the basis of available evidence, no specific recommendation can be made for early psychological interventions in children and adolescents with acute (secondary) insomnia in the first month after a potentially traumatic event.
Strength of recommendation: not applicable
Quality of evidence: low
Remarks
It is important always to assess for and manage other possible physical causes for insomnia, even when the insomnia starts within one month of a potentially traumatic event. This includes assessment of the child's perception as to why insomnia may be present. Where possible, environmental causes for insomnia (e.g. noisy environments) should be addressed.
Relaxation techniques and advice about sleep hygiene (see
recommendation 5
on psychological interventions for insomnia in adults) may be safe, feasible and potentially effective strategies in adolescents (age 10-19 years).
Health-care providers should explain that insomnia is common after exposure to extreme stressors. If insomnia persists for more than one month, the person should be reassessed for other conditions that may need treatment, including anxiety disorders (PTSD, generalized anxiety disorder, panic disorder), depressive disorder and, in adolescents, alcohol or drug use disorder.
There is already a
WHO (2010)
mhGAP recommendation to offer access to psychological first aid to people who have been recently exposed to potentially traumatic events. Therefore, as no further specific recommendation can be made, psychological first aid should be considered in children and adolescents with acute (secondary) insomnia in the first month after a potentially traumatic event.
7. Acute (secondary) insomnia (first month): pharmacological interventions – adults
Scoping question 7: For adults with acute (secondary) insomnia in the first month after a potentially traumatic event, do benzodiazepines, when compared to treatment as usual, waiting list or no treatment, result in a reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 7
Benzodiazepines should not be offered to adults with insomnia in the first month after a potentially traumatic event.
Strength of recommendation: standard
Quality of evidence: moderate
Remarks
It is important always to assess for and manage other possible physical causes for insomnia, even when the insomnia starts within one month of a potentially traumatic event. Where possible, environmental causes for insomnia (e.g. noisy environments) should be addressed.
There are alternatives to pharmacological treatment (see (a)
recommendation 5
on psychological interventions for insomnia in adults and (b)
WHO (2010)
mhGAP recommendations on psychological first aid).
In exceptional cases when psychologically oriented interventions are not feasible, short-term treatment (3–7 days) with benzodiazepines may be considered as a treatment option for insomnia that interferes severely with daily functioning. The following precautions should be considered: (a) there are possible interactions with other drugs; (b) necessary precautions should be taken when prescribing to elderly populations and pregnant or breastfeeding women; and (c) use of benzodiazepines can quickly lead to dependence in some people. Accordingly benzodiazepines should be prescribed for insomnia only in exceptional cases and for a very short time period. Benzodiazepines are often overprescribed.
Health-care providers should explain that insomnia is common after recent exposure to extreme stressors. If insomnia persists for more than one month, the person should be reassessed for other conditions that may need treatment, including anxiety disorders (PTSD, generalized anxiety disorder, panic disorder), depression and alcohol or drug use disorder.
8. Acute (secondary) insomnia (first month): pharmacological interventions – children and adolescents
Scoping question 8: For children and adolescents with acute (secondary) insomnia in the first month after a potentially traumatic event, do benzodiazepines, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 8
Benzodiazepines should not be offered to children and adolescents with acute (secondary) insomnia in the first month after a potentially traumatic event.
Strength of recommendation: strong
Quality of evidence: very low
Remarks
It is important always to assess for and manage other possible physical causes for insomnia, even when the insomnia starts within one month of a potentially traumatic event. Where possible, environmental causes for insomnia (e.g. noisy environments) should be addressed.
There are alternatives to pharmacological treatment (see
recommendation 6's remarks on psychological interventions for insomnia in children and adolescents).
Health-care providers should explain that insomnia is common after recent exposure to extreme stressors. If insomnia persists for more than one month, the person should be reassessed for other conditions that may need treatment, including anxiety disorders (PTSD, generalized anxiety disorder, panic disorder), depression and, in adolescents, alcohol or drug use disorder.
Enuresis after a potentially traumatic recent event (recommendation 9)
Enuresis is a common complaint in primary care for children recently exposed to potentially traumatic events and may have important harmful mental and social consequences, including decreased sense of self-worth, anxiety and harsh punitive parental reactions. The ICD-10 describes non-organic enuresis as “involuntary voiding of urine, by day and/or by night which is abnormal in relation to the individual's mental age and which is not a consequence of a lack of bladder control due to any neurological disorder, to epileptic attacks or to any structural abnormality of the urinary tract”. The GDG considered the evidence on management of enuresis, and developed the following recommendation.
9. Secondary non-organic enuresis (first month): early psychological interventions – children
Scoping question 9: In children with secondary non-organic enuresis after a potentially traumatic recent event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 9
Psycho-education about the negative effects of punitive responses should be given to caregivers of children with secondary non-organic enuresis in the first month after a potentially traumatic event.
Strength of recommendation: strong
Quality of evidence: very low
Parenting skills training and the use of simple behavioural interventions (i.e. star charts, toileting before sleep and rewarding having nights without wetting the bed) should be considered. In addition, where resources permit, alarms should be considered.
Strength of recommendation: standard
Quality of evidence: moderate for alarms, low or very low for other behavioural interventions
Remarks
Medical causes of bedwetting should be assessed and managed to ensure that the bedwetting is indeed secondary to a potentially traumatic event.
Health-care providers should explain that bedwetting is common after recent exposure to extreme stressors. If the bedwetting persists for more than one month, the child should be reassessed for other disorders that may need treatment.
Dissociative (conversion) disorders after a potentially traumatic recent event (recommendations 10–11)
Dissociative (conversion) disorders can, according to ICD-10, be “associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships”. Dissociative symptoms have been observed in varying ways (e.g. expressed through different psychological or somatic idioms of distress) in various cultures. The evidence search covered both psychological and somatoform dissociation in adults in the first month after a potentially traumatic event. The GDG considered the evidence retrieved, and it made two recommendations.
10. Symptoms of dissociative (conversion) disorders (first month): early psychological interventions – adults
Scoping question 10: For adults with symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 10
On the basis of available evidence, no specific recommendation can be made on psychological interventions for adults with symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event.
Strength of recommendation: not applicable
Quality of evidence: very low
Remarks
Possible physical causes for dissociation should be ruled out or managed.
There is already a
WHO (2010)
mhGAP recommendation to offer access to psychological first aid to people who have been recently exposed to potentially traumatic events. Therefore, as no further specific recommendation can be made, psychological first aid should be considered in adults with symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event.
For somatoform dissociation (i.e. conversion disorder), existing WHO guidance on the management of somatic medically unexplained symptoms may be considered (see Other Significant Emotional or Medically Unexplained Complaints module of the mhGAP Intervention Guide (WHO, 2010)).
Health-care providers should explain that these symptoms can sometimes occur after recent exposure to extreme stressors. When interacting with people with conversion disorder, clinicians should acknowledge suffering and maintain a relationship of respect with the person. At the same time they should carefully avoid reinforcing any secondary gain that the person may get from somatoform dissociation (conversion). The use of culturally appropriate interventions that are not harmful may be considered.
11. Symptoms of dissociative (conversion) disorders (first month): early psychological interventions – children and adolescents
Scoping question 11: For children and adolescents with symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event, do early psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 11
On the basis of available evidence, no specific recommendation can be made for children and adolescents with symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event.
Strength of recommendation: not applicable
Quality of evidence: very low
Remarks
Possible physical causes for dissociation should be ruled out or managed.
There is already a
WHO (2010)
mhGAP recommendation to offer access to psychological first aid to people who have been recently exposed to potentially traumatic events. Therefore, as no further specific recommendation can be made, psychological first aid should be considered in children and adolescents with symptoms of dissociative (conversion) disorders in the first month after a potentially traumatic event.
For somatoform dissociation (i.e. conversion disorder), existing WHO guidance on the management of somatic medically unexplained symptoms may be considered (see Other Significant Emotional or Medically Unexplained Complaints module of the mhGAP Intervention Guide (WHO, 2010)).
Health-care providers should explain that these symptoms can sometimes occur after recent exposure to extreme stressors. When interacting with people with conversion disorder, clinicians should acknowledge suffering and maintain a relationship of respect with the person. At the same time they should carefully avoid reinforcing any secondary gain that the person may get from somatoform dissociation (conversion). The use of culturally specific interventions that are not harmful may be considered.
Hyperventilation after a potentially traumatic recent event (recommendations 12–13)
Clinical experience suggests that in the immediate aftermath of potentially traumatic events, help-seeking for hyperventilation is common. Because symptoms are associated with hypocapnia, clinicians frequently encourage persons to increase their CO2 levels by rebreathing into a paper bag. The evidence search focused on whether rebreathing into a paper bag, compared to treatment as usual, waiting list or no treatment, results in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects.
12. Hyperventilation (first month): rebreathing into a bag – adults and adolescents
Scoping question 12: For adolescents and adults with hyperventilation in the first month after a potentially traumatic event, does rebreathing into a paper bag, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 12
No specific recommendation can be made on the basis of available evidence on rebreathing into a paper bag for adolescents and adults with hyperventilation in the first month after exposure to a potentially traumatic event.
Strength of recommendation: not applicable
Quality of evidence: very low
Remarks
There are significant risks if this technique is used in specific populations (e.g. people with heart disease and asthma).
Health-care providers should always rule out physical causes before considering psychological intervention for hyperventilation. They should maintain a calm approach, where possible remove sources of anxiety and coach respiration (i.e. encourage normal breathing, not deeper and quicker than usual).
Health-care providers should explain that hyperventilation can sometimes occur after recent exposure to extreme stressors. Acute stress should be managed using psychological first aid as per
WHO (2010)
mhGAP guidelines. Moreover, as per
recommendation 1
(on psychological interventions for acute traumatic stress symptoms in adults), cognitive-behavioural therapy with a trauma focus should be considered in adults with acute traumatic stress symptoms associated with significant impairment in daily functioning.
13. Hyperventilation (first month): rebreathing into a bag – children
Scoping question 13: For children with hyperventilation in the first month after a potentially traumatic event, does rebreathing into a bag, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 13
Rebreathing into a paper bag should not be considered for children with hyperventilation in the first month after a potentially traumatic event.
Strength of recommendation: standard
Quality of evidence: very low
Remarks
Health-care providers should always rule out physical causes before considering psychological intervention. They should maintain a calm approach, where possible remove sources of anxiety and coach respiration (i.e. encourage normal breathing, not deeper and quicker than usual).
Health-care providers should explain that hyperventilation can sometimes occur after recent exposure to extreme stressors. Acute stress in children should be managed using psychological first aid as per
WHO (2010)
mhGAP guidelines.
Posttraumatic stress disorder (recommendations 14–17)
Posttraumatic stress disorder (PTSD) is the most studied disorder occurring after exposure to potentially traumatic events. Psychological interventions for PTSD include individual and group cognitive-behavioural therapy (CBT), eye movement desensitization and reprocessing (EMDR), stress management and psycho-education for adult PTSD in non-specialized health-care settings. There is currently no consensus on the effectiveness of EMDR or pharmacological treatments between different clinical practice guidelines. For pharmacological interventions, the evidence search was limited to treatments most likely to be available now or in the next five years in non-specialized health care in low- and middle-income countries (tricyclic antidepressants (TCAs) and selective serotonin re-uptake inhibitors (SSRIs)) (cf. van Ommeren et al., 2005). The GDG considered the evidence for psychological and pharmacological interventions for PTSD and developed the following four recommendations.
14. Posttraumatic stress disorder (PTSD): psychological interventions – adults
Scoping question 14: For adults with posttraumatic stress disorder (PTSD), do psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 14
Individual or group cognitive -behavioural therapy (CBT) with a trauma focus, eye movement desensitization and reprocessing (EMDR) or stress management should be considered for adults with PTSD.
Strength of recommendation: standard
Quality of evidence: moderate for individual CBT, EMDR; low for group CBT, stress management
Remarks
Individual and group CBT with a trauma focus and EMDR should be offered only in those contexts where individuals are competent (i.e. trained and supervised) to provide the therapies. Although studies show that individual CBT with a trauma focus is more effective than stress management, in resource-constrained settings stress management may be the most feasible treatment option.
15. Posttraumatic stress disorder (PTSD): psychological interventions – children and adolescents
Scoping question 15: For children and adolescents with posttraumatic stress disorder (PTSD), do psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in a reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 15
Individual or group cognitive behavioural therapy (CBT) with a trauma focus or eye movement desensitization and reprocessing (EMDR) should be considered for children and adolescents with PTSD.
Strength of recommendation: standard
Quality of evidence: moderate for individual CBT, low for EMDR, very low for group CBT
Remarks
Individual and group CBT with a trauma focus and EMDR should be offered only in those contexts where individuals are competent (i.e. trained and supervised) to provide the therapies. Stress management may also be beneficial for children and adolescents with PTSD.
16. Posttraumatic stress disorder (PTSD): pharmacological interventions – adults
Scoping question 16: For adults with posttraumatic stress disorder (PTSD), do tricyclic antidepressants (TCAs) or selective serotonin re-uptake inhibitors (SSRIs), when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 16
Selective serotonin re-uptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) should not be offered as the first line of treatment for posttraumatic stress disorder in adults.
SSRIs and TCAs should be considered if:
stress management, CBT with a trauma focus and EMDR have failed or are not available;
or
if there is co-morbid moderate–severe depression.
Strength of recommendation: standard
Quality of evidence: low
Remarks
Interactions with other drugs need to be considered and necessary precautions should be taken when prescribing to elderly populations and pregnant or breastfeeding women (see
WHO (2010)
mhGAP Intervention Guide module on moderate–severe depression).
17. Posttraumatic stress disorder (PTSD): pharmacological interventions – children and adolescents
Scoping question 17: For children and adolescents with posttraumatic stress disorder (PTSD), do antidepressants, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 17
Antidepressants should not be used to manage PTSD in children and adolescents.
Strength of recommendation: strong
Quality of evidence: very low
Remarks
If there is concurrent moderate–severe depression, also use guidance for helping depressed children and adolescents as included in the
WHO (2010)
mhGAP Intervention Guide module on depression. There are alternatives to pharmacological treatment (see
recommendation 15
on psychological interventions for PTSD in children and adolescents).
Bereavement in the absence of mental disorder (recommendations 18–21)
Bereavement is referred to here as the event of a loss of a loved one, a common occurrence in life, which for most people will not lead to mental disorder. For a small minority, bereavement and grief may be associated with prolonged symptomatology and impairment in functioning amounting to mental disorder. The evidence considered concerned adults, children and adolescents who do not meet criteria for a mental disorder.
18. Bereavement: universally applied structured psychological interventions – adults
Scoping question 18: For bereaved adults without a mental disorder, do universally applied structured psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 18
Structured psychological interventions should not be offered universally to (all) bereaved adults who do not meet the criteria for a mental disorder.
Strength of recommendation: strong
Quality of evidence: moderate
Remarks
General principles of care, as reported in the
WHO (2010)
mhGAP Intervention Guide (particularly principles on communication, mobilizing and providing social support, and attention to overall well-being), and the principles of psychological first aid should be considered. Encourage participation in culturally appropriate mourning.
19. Bereavement: universally applied structured psychological interventions – children and adolescents
Scoping question 19: For bereaved children and adolescents without a mental disorder, do universally applied structured psychological interventions, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 19
Structured psychological interventions should not be offered universally to (all) bereaved children and adolescents who do not meet the criteria for a mental disorder.
Strength of recommendation: strong
Quality of evidence: very low
Remarks
General principles of care, as reported in the
WHO (2010)
mhGAP Intervention Guide (particularly principles on communication, mobilizing and providing social support, and attention to overall well-being), and principles of psychological first aid should be considered. Encourage participation in culturally appropriate mourning.
In cases where the child has lost a primary caregiver, the issue of protection and continued supportive caregiving, including socio-emotional support, should be addressed.
20. Bereavement: benzodiazepines – adults
Scoping question 20: For bereaved adults without a mental disorder, do benzodiazepines, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 20
Benzodiazepines should not be offered to bereaved adults who do not meet criteria for a mental disorder.
Strength of recommendation: strong
Quality of evidence: very low
Remarks
As mentioned in the remarks for
recommendation 18
on psychological interventions for bereaved adults, general principles of care, as reported in the
WHO (2010)
mhGAP Intervention Guide (particularly principles on communication, mobilizing and providing social support, and attention to overall well-being), and the principles of psychological first aid should be considered. Encourage participation in culturally appropriate mourning.
21. Bereavement: benzodiazepines – children and adolescents
Scoping question 21: For bereaved children and adolescents without a mental disorder, do benzodiazepines, when compared to treatment as usual, waiting list or no treatment, result in reduction of symptoms, improved functioning/quality of life, presence of disorder or adverse effects?
Recommendation 21
Benzodiazepines should not be offered to bereaved children and adolescents who do not meet criteria for a mental disorder.
Strength of recommendation: strong
Quality of evidence: very low
Remarks
As mentioned in the remarks for
recommendation 19
on psychological interventions for bereaved children and adolescents, general principles of care, as reported in the
WHO (2010)
mhGAP Intervention Guide (particularly principles on communication, mobilizing and providing social support, and attention to overall well-being), and principles of psychological first aid should be considered. Encourage participation in culturally appropriate mourning.
In cases where the child has lost a primary caregiver, the issue of protection and continued supportive caregiving, including socio-emotional support, should be addressed.
