Maryam Bibi

BUILDING A NATIONAL SYSTEM FOR MENTAL HEALTH & SUICIDE PREVENTION AND RESPONSE Policy frameworks, and crisis response mechanisms Table of Contents Background 01 Objectives 02 System Components 03 A. DHIS2 Tracker: Integrated Mental Health & Suicide Case Tracking 03 1. Target Group: 03 2. Tracked Entity Attributes (TEAs): 03 Section 1: Personal Information 03 Section 2: Socio-Demographic Details 03 3. Program Stage 1: Screening & Risk Assessment 04 e. Bipolar Disorder (MDQ Screening) 07 4. Program Stage 2: Clinical Assessment & Diagnosis 08 5. Program Stage 3: Treatment & amp; Counseling 10 6. Program Stage 4: Follow-up & amp; Monitoring 10 7. Program Stage 5: Outcome & Case Closure 10 B. DHIS2 Aggregate Module: Integrated Mental Health & Suicide Surveillance 11 1. Target Group: 11 2. Reporting Units: 11 3. Core Data Elements (Monthly/Quarterly Reporting): 11 4. Key Indicators: 11 Expected Outcomes 12 Conclusion 12 Background Mental health and suicide are growing public health concerns in Pakistan, with millions affected by Depression & Anxiety, Substance Use Disorders, Schizophrenia & Other Psychotic Disorders, Obsessive‑Compulsive Disorder (OCD), Bipolar Disorder & PTSD, alongside thousands of lives lost each year to suicide. Despite their severity, these conditions remain underreported, misunderstood, and largely excluded from comprehensive national health planning. Social stigma, limited awareness, legal implications (in the case of suicide), weak reporting systems, and the absence of an integrated mental health and suicide registry have contributed to the invisibility of this burden. Currently, Pakistan lacks an integrated, real-time system for collecting and analyzing data on mental health disorders and suicide. Data is often fragmented across hospitals, clinics, rehabilitation centers, police records, and community reports none of which are systematically linked or validated. Patients with mental health disorders, particularly those who survive suicide attempts, are rarely tracked or supported through structured follow-up care. To address these challenges, this concept note proposes a unified DHIS2-Based Mental Health and Suicide Surveillance System: A Tracker module to register and follow up on individuals with the six priority mental health conditions. An Aggregate reporting module to capture and analyze trends for all conditions and suicide deaths. This integrated system will support early intervention, enable accurate national reporting, and inform policy and programming for mental health and suicide prevention, aligned with WHO’s Mental Health Action Plan and Pakistan’s digital health vision. The Project Suicide (TPS) is a pioneering youth-led initiative addressing the urgent and under recognized challenge of mental health and suicide in Pakistan. Through its awareness and advocacy efforts, TPS has highlighted the need for systemic, data-driven solutions to break stigma and strengthen prevention and response. To advance this vision, TPS is collaborating with HISP Pakistan, a nationally recognized leader in digital health innovation and a core member of the global Health Information Systems Program. HISP Pakistan has successfully designed and implemented DHIS2-based platforms for national health programs, including TB surveillance, provincial HMIS, and case-based digital trackers, enabling real-time data use for decision-making. Leveraging this proven expertise, HISP Pakistan will provide the technical backbone for developing Pakistan’s first integrated digital system for mental health and suicide prevention positioning TPS as the first mover in combining grassroots engagement with digital health innovation. Page 01 Objectives 1. To design and deploy a case-based DHIS2 Tracker for individuals diagnosed with or suspected to have Depression & Anxiety, Substance Use Disorders, Schizophrenia & Other Psychotic Disorders, OCD, Bipolar Disorder & PTSD, as well as individuals who survive suicide attempts. 2. To establish a DHIS2 Aggregate reporting mechanism for documenting and analyzing new cases, follow-up care, recovery outcomes, and suicide deaths. 3. To enable real-time risk monitoring, follow-up care, and cross-sectorial referrals for patients. 4. To support national mental health and suicide prevention strategies through evidence-based data collection, early warning, and resource planning. Page 02 System Components A. DHIS2 Tracker: Integrated Mental Health & Suicide Case Tracking 1. Target Group: Patients diagnosed with or suspected to have any of the six priority mental health conditions (Depression & Anxiety, Substance Use Disorders, Schizophrenia & Other Psychotic Disorders, OCD, Bipolar Disorder & PTSD) as well as individuals who survive suicide attempts. 2. Tracked Entity Attributes (TEAs): Sections for Personal Information and SocioDemographic Details remain as in the original suicide module: Section 1: Personal Information Unique Patient ID (Text – System-generated or assigned unique identifier) Full Name (Text – Patient’s complete name) CNIC / National ID (Text – Government-issued identity number) Date of Birth (Date – Patient’s birth date) Gender (Option Set – Male, Female, Other, Prefer not to say) Contact Number (Text – Phone number for contact) Address (District/UC) (Text – Include district and union council details) Section 2: Socio-Demographic Details Education Level (Option Set – No formal education, Primary, Secondary, Higher Secondary, Graduate, Postgraduate, Other) Occupation (Text – Patient’s occupation) Marital Status (Option Set – Single, Married, Divorced, Widowed, Other) Referral Source (Option Set – Self, Family, Health Facility, Community Health Worker, Other) Consent for Data Use (Yes/No – Consent obtained for data collection and use) Page 03 3. Program Stage 1: Screening & Risk Assessment Each patient will be screened using standardized tools depending on their presenting symptoms. The following sub-sections outline the screening and risk assessment components by condition: a. Depression To assess the severity of depressive symptoms over the past 2 weeks. Ask the following questions. For each, select one of the following options: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day PHQ-9 Questions: • Little interest or pleasure in doing things • Feeling down, depressed, or hopeless • Trouble falling or staying asleep, or sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself — or that you are a failure or have let yourself or your family down • Trouble concentrating on things, such as reading or watching television • Moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that you've been moving a lot more than usual • Thoughts that you would be better off dead, or thoughts of hurting yourself in some way Functional Impact Question: • If you checked off any problems above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Options: Not difficult at all Somewhat difficult Very difficult Extremely difficult Scoring (for backend): Total score is the sum of questions 1–9 (range: 0–27) Interpretation: 0–4: Minimal or no depression 5–9: Mild depression 10–14: Moderate depression 15–19: Moderately severe depression 20–27: Severe depression Page 04 b. Anxiety To assess the severity of generalized anxiety over the past 2 weeks. Instructions: Ask the following questions. For each, select one of the following options: 0= 1 = 2 = 3= Not at all Several days More than half the days Nearly every day GAD-7 Questions: • Feeling nervous, anxious, or on edge • Not being able to stop or control worrying • Worrying too much about different things • Trouble relaxing • Being so restless that it is hard to sit still • Becoming easily annoyed or irritable • Feeling afraid as if something awful might happen Functional Impact Question: • If you checked off any problems above, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Options: Not difficult at all Somewhat difficult Very difficult Extremely difficult Scoring (for backend): Total score is the sum of all 7 questions (range: 0–21) Interpretation: 0–4: Minimal or no depression 5–9: Mild depression 10–14: Moderate depression 15–19: Moderately severe depression Page 05 c. Substance Use Disorder To screen for problematic use of alcohol, tobacco, and other substances. Instructions: Ask each question below for every substance category used by the person. Substances include: Tobacco, Alcohol, Cannabis, Sedatives, Opioids, Cocaine, Inhalants, Hallucinogens, Other. Core Questions (Per Substance): • In your lifetime, have you ever used this substance? (Yes/No) • In the past 3 months, how often have you used it? Never Once or twice Monthly Weekly Daily or almost daily • Has anyone ever expressed concern about your substance use? • Have you ever failed to meet responsibilities because of use? • Have you ever tried and failed to cut down? • Have you ever experienced health, legal, financial, or social problems due to use? • Have you ever had withdrawal symptoms or cravings? Scoring (per substance): • Risk is categorized as: Low Risk Moderate Risk High Risk d. Obsessive‑Compulsive Disorder (OCD) To detect presence of obsessive thoughts and compulsive behaviors. Instructions: Ask the following questions. Each may be answered Yes/No and followed by severity where applicable. OCD Questions: • Do you have unwanted, repetitive thoughts that are difficult to control or ignore? •Do you engage in repetitive behaviors (e.g., washing, checking, counting, repeating words) to relieve anxiety? •Do these thoughts or behaviors take up a lot of your time (more than 1 hour/day)? •Do they interfere with your ability to function at work, school, or home? •Have you tried to resist or reduce these thoughts or actions? •How much distress do these thoughts/behaviors cause you? Scoring (optional): • Severity of symptoms can be categorized as: Mild Moderate Severe Page 06 e. Bipolar Disorder (MDQ Screening) To screen for symptoms of mania or hypomania consistent with Bipolar I or II. Instructions: The following Yes/No questions. For “Yes” answers, assess timing and impact. MDQ Questions: 1.Have you ever had a period where you felt unusually energetic, overly happy, or irritable for several days or longer? 2.During that time, did you experience any of the following (Yes/No for each): Increased talkativeness or rapid speech Needing less sleep and still feeling rested Racing thoughts or jumping from topic to topic Increased self-confidence or sense of grandiosity More physical activity or restlessness than usual Doing things you later regretted (e.g., risky spending, driving, sexual behavior) 3. Did several of these symptoms occur at the same time? 4. Did these changes cause problems for you or those around you (e.g., legal, financial, personal)? Scoring (optional): ≥7 symptoms present Symptoms occurred simultaneously Symptoms caused moderate or serious problems f. Suicide Risk Assessment To assess suicidal thoughts, intent, and behavior. Instructions: Ask the following Yes/No questions and document any details shared. Suicide Risk Questions: • Have you wished you were dead or wished you could go to sleep and not wake up? • Have you actually had thoughts of killing yourself? • Have you been thinking about how you might do this (e.g., method)? • Do you intend to act on these thoughts? • Have you ever tried to kill yourself? • How many past suicide attempts have you made? • What triggered these thoughts or actions (stressors)? • Do you have access to means (e.g., medications, weapons)? • Are you receiving any support from family, friends, or community? Page 07 Risk Categorization (based on responses): Low Risk: Ideation only, no plan or intent Moderate Risk: Ideation with method or intent, no plan High Risk: Active intent, plan, or previous attempt Very High Risk: Immediate intent or recent attempt 4. Program Stage 2: Clinical Assessment & Diagnosis To assign a formal diagnosis based on international standards (DSM-5 or ICD-11), document co-morbidities, and record clinical observations and diagnostic tools used. Diagnosis & Coding • Record the date of clinical assessment • Select the diagnosis coding system used (DSM-5 or ICD-11) • Select the primary mental health diagnosis • Record the official diagnostic code from the selected system • Select any co-morbid mental health conditions • Assign severity level of diagnosis (Mild, Moderate, Severe, Very Severe) • Record name and designation of diagnosing provider Diagnostic Categories DSM-5 Categories • Depressive Disorders (e.g., Major Depressive Disorder, Dysthymia) • Anxiety Disorders (e.g., Generalized Anxiety Disorder, Panic Disorder) • Substance Use Disorders (e.g., Alcohol Use Disorder, Opioid Use Disorder) • Schizophrenia Spectrum and Other Psychotic Disorders • Obsessive-Compulsive and Related Disorders • Bipolar and Related Disorders • Trauma- and Stressor-Related Disorders (e.g., PTSD) • Personality Disorders (e.g., Borderline, Antisocial) • Other Specified or Unspecified Mental Disorders ICD-11 Categories • MB24 – Depressive disorders • MB23 – Anxiety and fear-related disorders • MB26 – Substance use and addictive behaviors • MB20 – Schizophrenia or other primary psychotic disorders • MB25 – Obsessive-compulsive and related disorders • MB21 – Bipolar disorders • MB22 – Disorders associated with stress (e.g., PTSD) • MB30 – Personality disorders • MB99 – Other specified/unspecified mental disorders Page 08 Clinical Assessment Tools (Opened Up) PHQ-9 – Depression Tailoring Treatment 9-item questionnaire assessing depressive symptoms over the past 2 weeks Scoring from 0–27, with categories from minimal to severe depression GAD-7 – Generalized Anxiety Disorder 7-item scale to assess severity of anxiety symptoms Scoring from 0–21; higher scores indicate more severe anxiety Identifying Disorders ASSIST – Substance Use (WHO) Screens for tobacco, alcohol, cannabis, sedatives, opioids, etc. Assesses frequency of use, problems, cravings, failed attempts to quit Determining Treatment Levels Y-BOCS – Obsessive-Compulsive Disorder Evaluates intrusive thoughts and compulsive behaviors Assesses time consumed, distress caused, resistance, and control MDQ – Bipolar Disorder Monitoring Progress Screens for elevated mood, increased activity, risk-taking behavior Includes impairment and symptom clustering criteria C- SSRS – Suicide Risk Enhancing Effectiveness Assesses severity of suicidal thoughts, intent, plan, and previous attempts Categorizes risk as low, moderate, high, or very high MINI (Mini International Neuropsychiatric Interview) Structured diagnostic interview covering multiple DSM/ICD diagnoses Often used for comprehensive assessments in clinical settings Page 09 Clinical Notes Summarize clinical observations, history, presenting problems, recent stressors, family/social context Record functional impairment, current support systems, and any red flags. 5. Program Stage 3: Treatment & Counseling Date of Counseling / Treatment Session Type of Therapy Provided (CBT / DBT / Supportive Counseling / Group Therapy / Crisis Intervention / Rehabilitation Program for Substance Use / Other) Duration of Session (minutes) Name of Therapist / Counselor / Clinician Medications Prescribed (list name(s)) Dosage and Frequency for each medication Treatment Adherence (Fully Adherent / Partially Adherent / Non-Adherent) Counseling Session Notes (key points, progress, recommendations) Referral Made To (Psychiatrist / Psychologist / Social Worker / Psychiatric Hospital / Emergency Services / Other) 6. Program Stage 4: Follow-up & Monitoring Date of Follow-up Visit Current Mental Health Status (Stable / Improving / No Change / Worsening) Treatment Adherence (Fully Adherent / Partially Adherent / Non-Adherent) Side Effects Experienced (Yes / No – If Yes, describe) Suicide Risk Reassessment Score / Category (Low / Moderate / High / Very High) Support System Evaluation (Strong / Moderate / Weak / None) Self-Reported Progress (patient’s own words) Next Scheduled Appointment Date 7. Program Stage 5: Outcome & Case Closure To formally record the final status of the patient’s case in the program, summarize progress, and determine whether the case can be closed or requires ongoing monitoring. Case Outcome (Recovered / Improved / Unchanged / Deceased / Relapse / Ongoing Care) Date of Case Closure Cause of Death (if applicable) Final Clinical Notes Page 10 B. DHIS2 Aggregate Module: Integrated Mental Health & Suicide Surveillance 1. Target Group: All confirmed cases of the six conditions and suicide deaths, reported from health facilities, mental health institutions, CRVS, police, and community surveillance 2. Reporting Units: Basic Health Units (BHUs) Rural Health Centers (RHCs) Tehsil and District Headquarters Hospitals (THQs/DHQs) Psychiatric hospitals and mental health institutions Rehabilitation centers for substance use disorders CRVS offices Police stations / medico-legal units Community health workers (LHWs, NGOs) 3. Core Data Elements (Monthly/Quarterly Reporting): New cases by disorder, age group, sex, and district. Suicide deaths by method, location, and demographic. Comorbidity with substance use or other disorders. Treatment coverage, follow-up rate, and recovery rate. 4. Key Indicators Prevalence and incidence rates per disorder. Suicide mortality rate per 100,000. % of cases with follow-up within 30 days. Treatment adherence and completion rates. Page 11 Expected Outcomes The integrated DHIS2-based system will establish Pakistan’s first national registry for priority mental health conditions and suicide cases, ensuring that every diagnosed patient is documented, followed up, and supported through a structured continuum of care. By enabling real-time data capture from both community and facility levels, the system will allow for early detection of high-risk individuals and timely intervention before crises escalate. Through accurate, disaggregated data analyzed by age, gender, location, and condition, the system will uncover hidden trends, identify hotspots, and guide targeted resource allocation. This evidence base will directly strengthen referral pathways between community health workers, primary care, and specialist mental health services—ensuring that patients receive the right care at the right time. By shifting from fragmented, reactive responses to a coordinated, prevention-focused model, the system will empower mental health professionals to conduct proactive outreach, deliver timely psychosocial support, and provide rehabilitation services where they are needed most. Ultimately, it will position Pakistan as a leader in integrated mental health and suicide surveillance, while offering a scalable model that can be replicated across other low- and middle-income countries. This DHIS2-based dual surveillance system represents a critical advancement in Pakistan’s mental health infrastructure. By enabling real-time tracking of patients with the six major mental health conditions and consolidating mortality data from multiple sectors, it addresses long-standing gaps in reporting, response, and policy. Its integration into existing health and surveillance structures will empower stakeholders with timely, actionable data—paving the way for more effective prevention strategies, improved patient outcomes, and stronger mental health governance nationwide. Page 12 Contact Us Website www.hisp.org..pk Address HISP Pakistan. Jinnah Ave, Islamabad E-mail- linkedin Health Information Systems Program