II. Clinic Indicators 1. Health Facility Staff Number and type of Male Fem Average clinical hours/day Average # of patients seen/day Average time (minutes) spent with patient Task/Service provided GPs/Family Doctors Nurses Midwives Social Worker Psychologist Mental Health Nurse Psychiatrist CHWs Other: Notes and Recommendations: 2. Basic Pharmacy Data Medication (please circle available) Availability in the PHC clinic or nearby pharmacy in the previous week Generic antidepressant medication (amitriptyline, fluoxetine) ⓪ Never/rarely ① Sometimes ② Usually/always Generic anti-anxiety medication (diazepam) ⓪ Never/rarely ① Sometimes ② Usually/always Generic anti-psychotic medication (haloperidol tab and inj, chlorpromazine, Thioridazine) ⓪ Never/rarely ① Sometimes ② Usually/always Generic anti-epileptic medication (phenobarbital carbamazepine, diazepam inj, valproic acid) ⓪ Never/rarely ① Sometimes ② Usually/always Generic bipolar disorder medication (valproic acid, carbamazepine) ⓪ Never/rarely ① Sometimes ② Usually/always Medication as part of substance use programs (nicotine replacement therapy) ⓪ ① Sometimes ② Usually/always Generic antiparkinsonian medicine for the management of side effects from antipsychotic medication (biperiden) ⓪ Never/rarely ① Sometimes ② Usually/always 2. Average Score (= sum of all scored items divided by total # of items scored) ( ) Notes and Recommendations: 3. Basic Laboratory Services Availability Do have laboratory service in your health center? ⓪ No ② Yes
Assessment of people with mental, neurological and substance use problems ⓪ No ② Yes Moderate-severe Depressive Disorder (DEP) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Psychosis (PSY) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, Epilepsy/Seizures (EPI) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Acute Stress (ACU) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Grief (GRI) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Post-traumatic Stress Disorder (PTSD) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Intellectual Disability (ID) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Harmful Use of Alcohol and (SUB) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Suicide (SUI) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Other Significant Mental Health Complaints (OTH) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Other disorders** Bipolar disorder ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Child Behavioral Disorders (ADHD, conduct) ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Dementia ⓪ No ② Yes If yes, please circle: psycho-education, psychological interventions, pharmacological interventions, other: Other Relevant Training Psychological Interventions (e.g. problem solving plus, IPT, thinking healthy) ⓪ No ② Yes Psychological first aid (PFA) ⓪ No ② Yes
Other: ⓪ No ② Yes 5. Average Score (= sum of all scored items divided by total # of items scored) Notes and Recommendations: * It is recommended to only score those mental disorders which should be managed at the PHC level as per national guidelines if they exist. Note that depression, psychotic disorders and epilepsy are considered priority conditions in humanitarian emergencies (part of WHO MH MISP). ** not part of Humanitarian Intervention Guide (HIG). 6. Staff roles and team work Staff Roles Yes/No Specifics Staff have defined roles in identification, management and referral of mental disorders ⓪ No ① Yes, but roles not followed ② Yes and roles are followed If yes, specify how: Discussion about persons with mental disorders takes place ⓪ No ① Yes, informally ② Yes in regular (weekly or bi-weekly) meetings If yes, specify who participates: 6. Average Score (= sum of all scored items divided by total # of items scored) ( ) and Recommendations: 7. Service Provision Indicators Type of Case * # of cases (if known) In the past the following was provided for this diagnostic category… According to the clinic’s health information system in the last month, service was provided for: Identified at the PHC level Treated at the PHC Referred to specialized MH care Moderate-severe Depressive Disorder (DEP) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Psychosis (PSY) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Epilepsy/Seizures (EPI) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Stress (ACU) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Grief (GRI) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Post-traumatic Stress Disorder (PTSD) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes Intellectual Disability (ID) ⓪ No ② Yes ⓪ No ② Yes ⓪ No ② Yes
If yes, the reports are also separated by gender and age for analysis ⓪ No ② Yes Reporting categories used for mental, neurological and substance use disorders ⓪ None ① 1 category (e.g.MNS) ② Several categories (e.g. UNHCR HIS) To Interviewer: If report is available please attach to the checklist 9. Average Score (= sum of all scored items divided by total # of items scored) ( ) Notes and Recommendations: 10. Social Indicators The Health Facility has the following characteristics: The health care facilities is in safe walking distance of affected/target communities ⓪ No ② Yes Health care provision is organized in a way that respects privacy (e.g. curtain around consultancy area, private room) ⓪ No ② Yes Services are provided: free of charge $ per consultation: _____ At least 1 staff member per clinic speaks the local language or dialect(s) ⓪ No ② Yes N/A 10. Average Score (= sum of all scored items divided by total # of items scored) ( ) Notes and Recommendations: 11. Referral indicators 11a. Health know: Referral options to the specialized mental health services (e.g. staff know the location, contact, costs and referral procedures for closest specialized services) ⓪ No ② Yes Contacts: Referral options to the protection agencies/social services (e.g.concerns regarding physical and sexual abuse of children and adults) ⓪ No ② Yes Contacts: Referral & follow up protocol for emergency including at-risk patients (e.g. cases of ⓪ No ② Yes Details: 11. Average (= sum of all scored items divided by total # of items scored) 11a ( ) 11b. In the last 2 weeks mental health-related referrals occurred to PHC from: