Special Considerations

Intellectual Disability

Older Patients (≥45 years)

Sexual Health and Sexuality

Maternal Mental Health

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Intellectual Disability

ICD-10 code: F70.0-1/F70.8-9/F71.0-1/F71.8-9/F72.0-1/F72.8-9/F73.0-1/F73.8-9/F78.0-1/F78.8-9/F79.0-1/F79.8- 9/F84.1/F84.4 + (Z13.3/Z81.0/Z81.8)

• Difficulty with verbal communication in the patient may result in over diagnosis of psychiatric conditions.
• More time is needed in the consultation and to obtain adequate history from family members.
• High risk of being victims of sexual and physical violence by family, neighbours, or strangers – maintain high index of suspicion for abuse.
• Physical discomfort, e.g., pain or constipation, may present as emotional distress.
• Emotional distress, fear, anxiety, or depression may cause aggression or odd behaviour.
• A supportive, caring, and secure environment is essential for well-being and contained behaviour.
• Manage together with social workers, occupational therapists, counsellors, and nonhealth departments, e.g. social development and education.
• Consider anxiety, depression, and epilepsy before psychosis.
• Use lowest possible doses of medication to achieve desired effect.
• Placement in a residential facility may be necessary. Requires referral to a social worker and may require completion of one MHCA Form 04 and two Form 05s depending on the mental health status of the user.

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Older Patients (≥45 years)

• New psychiatric diagnoses are uncommon in the older patient.
• Actively exclude medical causes, e.g. anaemia, pain, constipation, dementia, chronic kidney disease, COPD, malignancy.
• Older patients are very sensitive to the side effects of psychiatric medications. Use lowest possible dose to achieve desired effect.
• Consult with family/carers: educate about the condition and provide support by explaining how to manage behaviour at home.
• Refer family/carers to social worker or counsellor for further support.

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Sexual Health and Sexuality

ICD-10 code: F52.0-9

Sexual problems may be more frequent amongst people with mental illness or neuropsychiatric conditions:

• Low sex drive, anorgasmia (unable to achieve an orgasm), or impotence may occur as part of the mental illness, as a result of medication side effects (e.g. fluoxetine), and/or substance use.
• Hyper-sexuality may occur in people with intellectual disability, in manic or psychotic states, emotional dysregulation, or substance use disorders.
• Specific sexual disorders, e.g. vaginismus (spasm of vagina) or other sexual dysfunction require specialist treatment.
• Refer for assessment and appropriate treatment.

Mental illness is more common amongst people with alternative sexual orientations or who are transgender.

• Stigma, discrimination, and victimisation increase the prevalence of mental illness amongst this group of people.
• Response to treatment will be poor if underlying issues are not expressed and managed.
• Disclosure to staff depends on a non-judgemental, accepting environment.
• Refer to counsellor/social worker.
• Counsel family members and caregivers.
• Refer to psychiatrist depending on clinical presentation/need.

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Maternal Mental Health

Details regarding maternal mental healthcare are provided in:

• Primary Health Care STGs: Maternal mental health.
• Adult Hospital STGs: Mental health conditions and substance misuse.

Click here for the pdf

Click here for the circular

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Standard Treatment Guidelines and Essential Medicines List for South Africa Primary Healthcare Level_Chapter 16: Mental Health Conditions_NEMLC Recommendations for Medicine Amendments 2020_2023