|

 

Ps201500508_pap_ps 1.3

GLOBAL MENTAL HEALTH REFORMS Outpatient Mental Health Services in Mozambique: Useand TreatmentsBradley H. Wagenaar, M.P.H., Ph.D., Vasco Cumbe, M.D., M.P.H., Manuela Raunig-Berhó, B.A., Deepa Rao, M.A., Ph.D.,Brandon A. Kohrt, M.D., Ph.D., Andy Stergachis, Ph.D., Manuel Napúa, M.D., Kenneth Sherr, M.P.H., Ph.D.
To describe current outpatient mental health service use and women was more likely for mood and neurotic disorders and treatments in Mozambique, the authors reviewed registry less likely for substance use disorders and epilepsy. First- entries for 2,071 outpatient psychiatric visits at the Beira generation antipsychotics, most often paired with pro- Central Hospital in Sofala Province from January 2012 methazine, dominated treatment regimens. Evidence-based to September 2014. Service use was most common for reforms are needed to improve identification of mood dis- schizophrenia, followed by epilepsy, delirium, and organic orders and broaden care beyond severe mental disorders.
behavioral disorders. Only 3% of consultations for schizo-phrenia were first-visit patients. Treatment seeking among Psychiatric Services in Advance (doi: 10.1176/appi.ps.201500508) Across Mozambique, prevention, care, and treatment of staff, although stock-outs are common, and certain essential mental disorders have been historically neglected compared medications are not available (2).
with other health conditions. As of 2011, the Ministry of The objective of the assessment reported here was to Health in Mozambique allocated only .16% of the total health address a gap in the peer-reviewed literature documenting budget to mental health services. This neglect of service current outpatient mental health utilization patterns, along provision occurs at a time when mental, neurological, and with treatment patterns. This study was conducted at the substance use disorders are recognized as the primary Beira Central Hospital, one of three central hospitals in drivers of disability worldwide. A 2011 report that imple- Mozambique. The hospital employs numerous specialists mented the World Health Organization's Assessment Instru- and serves all of central Mozambique, providing 26% of all ments for Mental Health Systems (WHO-AIMS) indicated outpatient mental health consultations in Sofala Province.
that the most common outpatient psychiatric consultations in Because it generally has better availability of mental health Mozambique were for epilepsy (53%), child mental disorders medicines (2) and specialists, it likely serves patients with (15%), and schizophrenia (14%) and that 40% of mental more severe illness.
health consultations were for women (1).
There are fewer than 15 psychiatrists in public-sector Data and Analysis Procedures service in Mozambique, and the vast majority of mental healthcare is provided by psychiatric technicians who undergo a We reviewed 2,071 outpatient psychiatric registry entries two-year training program after acquiring at least a tenth- from January 2012 to September 2014. Registries are hand grade education. This program is a major success of the written with one line per patient, including the consultation Ministry of Health. Even with very limited financial resources date, age, sex, visit number (first or two or more), diagnosis, for mental health services, the number of psychiatric tech- treatments provided, and corresponding ICD-10 code. Two nicians working nationally increased from 66 in 2010 to 241 trained abstractors manually entered data into Excel 2013.
as of December 2014. These technicians are placed mainly Inconsistencies between abstractors and instances of illegi- at district-level referral hospitals, and the government has ble handwriting were resolved by revisiting the registry and recently achieved the goal of placing one technician in each cross-checking with responsible staff.
of the 135 districts. Psychiatric technicians are able to diag- Outpatient ICD-10 diagnosis groupings and individual nose all categories of mental health conditions and treat them diagnoses were analyzed by continuous age and percentage by using brief psychotherapy and all therapeutic categories of females. Individual diagnoses were tabulated, and the four of psychotropic medications. Psychotropic medications are most common primary diagnoses within each ICD-10 di- generally available at facilities with trained mental health agnostic grouping are reported. All treatment regimens were GLOBAL MENTAL HEALTH REFORMS tabulated for each of the four most common individual di- females were four times more likely than males to receive a agnoses, and the three most common regimens for each di- diagnosis of depressive illness. This is surprising because in agnosis are presented. Two-sample t tests were used to most settings, the prevalence of major depressive disorder is compare continuous age distributions. Chi square tests were estimated to be twice as high among women than men (4).
used to test for gender differences. Fisher's exact tests were The elevated mean age of those seen for depressive illness used if any cell was less than five. Individuals with missing (40–45 years) may indicate heterogeneity in diagnoses, care data on a given factor were excluded for analyses of that seeking, or prevalence of depression by age—important variable. Stata 13 was used for statistical analyses. All tests questions for future studies.
were two-tailed with an alpha value of .05.
With only five total cases of bipolar disorder diagnosed among 2,071 consultations and the relatively stable pop-ulation point prevalence of .7%21% globally (5), it seems Findings and Practical Implications likely that bipolar disorder may be routinely misdiagnosed.
Service Use. The study provided gender and age profiles of This could represent a missed opportunity for suicide pre- common diagnoses by ICD-10 code, as well as typical treat- vention, given that individuals with bipolar disorder are ment regimens, for more than 2,000 outpatient consulta- estimated to be 60 times more likely than the general pop- tions over a 20-month period. We found that use of ulation to die from suicide (6).
outpatient mental health care at the Beira Central Hospital As expected, given the cultural climate around psycho- was primarily by individuals under age 36 (61% age #35) active substance use, males were more likely to be given who were seeking care for severe mental illnesses, namely diagnoses of substance use disorders. A previous population- schizophrenia and schizotypal or delusional disorders, level study of alcohol consumption in Mozambique found which accounted for over 40% of all outpatient consulta- only a twofold higher prevalence of current alcohol drinking tions. Schizophrenia was the single most common diagnosis, among men compared with women (7). Our study found a accounting for almost 30% of all outpatient consultations.
nearly ninefold higher prevalence among males, which [Tables presenting demographic and clinical data are in- could result from either underuse of treatment or under- cluded in an online supplement to this column.] Overall, less diagnosis among females with substance-related issues, po- than 14% of all outpatient consultations were for new pa- tentially because of strong stigma associated with females' tients. Among visits by patients with common diagnoses, use of psychoactive substances.
schizophrenia accounted for the lowest proportion of first-visit patients—less than 4% of consultations were for new Treatment Patterns and Quality. The first-generation anti- patients. These findings are concerning because they indi- psychotics trifluoperazine, fluphenazine, decanoate of flu- cate that few new patients are entering the outpatient care phenazine, haloperidol, and chlorpromazine—all of which are system. Cross-national studies from other settings indicate on the national essential medication list (2)—were the most that schizophrenia does not have differential incidence or common treatment regimens for most types of organic dis- prevalence by gender. Therefore, it is encouraging that no orders, as well as for psychoactive substance use, schizo- significant gender differences were found in service use for phrenia and delusional disorders, and intellectual disability.
schizophrenia in our sample. In addition, overall mental Most often, these first-generation antipsychotics were pre- health service use was almost perfectly balanced between scribed alongside promethazine—an unusual combination be- genders, an indicator that services may be skewed toward cause promethazine is not a first-line treatment for prevention severe illness and away from common mood disorders, be- of extrapyramidal side effects in high-income countries nor cause across diverse global primary care settings depression is it recommended in the WHO Mental Health Gap Action is twice as prevalent among women.
Program (WHO mhGAP).
Epilepsy was the second most common outpatient psy- Evidence-based guidelines from WHO mhGAP state that chiatric diagnosis. Patients with epilepsy were significantly anticholinergics should not be routinely prescribed to pre- younger than patients in the average consult and more likely vent the development of extrapyramidal side effects, should to be male (60% of cases). These data suggest that men may be considered only for short-term use among patients with have a higher burden of epileptic disorders in central significant existing side effects, and should not be prescribed Mozambique; this is not surprising, because studies indicate for long-term use by pregnant women. Given that a large that men may have a higher incidence of epilepsy in other proportion of patients treated in this setting are women sub-Saharan African countries (3). Gender differences may of reproductive age and that promethazine is not first-line be especially important for neurotic and mood disorders.
treatment for the prevention or treatment of extrapyrami- These conditions were rarely diagnosed in our outpatient dal symptoms, the routine pairing of promethazine or other sample (only 4.7% and 1.9%, respectively), and patients with anticholinergic agents with first-generation antipsychotics these diagnoses were more likely to be female. For example, should be reviewed. Moreover, antipsychotics and anticho- 87% of patients with a depressive episode, 73% of patients linergics are contraindicated in the treatment of delirium with adjustment disorder, and all patients given a diagnosis and dementia, with an increased mortality risk, although this of bipolar disorder were female. These findings indicate that was the treatment of choice in our sample. As evidence-based GLOBAL MENTAL HEALTH REFORMS guidelines recommend biperiden for first-line treatment commonly for schizophrenia, epilepsy, and delirium or of extrapyramidal side effects, its availability could be other organic disorders. Mood disorders, although hy- prioritized and going forward it could be used in place of pothesized to have high population prevalence, are cur- rently not well addressed. To address the low rate of mood The most cost-effective treatment for schizophrenia in disorder identification, implementation of rapid screening lower–middle-income countries (LMICs) includes antipsy- tools, such as the Patient Health Questionnaire–2, could be chotics plus psychosocial interventions, which increase considered alongside increased efforts to integrate mental improvement by 15% to 26% compared with no treatment health care into primary care. For most diagnoses, medi- (8). Similarly, evidence-based recommendations suggest that cation use currently focuses on first-generation antipsy- diazepam is preferable to manage acute alcohol withdrawal chotics routinely paired with promethazine or another and that antipsychotics are not indicated as stand-alone anticholinergic agent. Some regimens may not be following treatment. In the outpatient setting in Mozambique, an in- up-to-date guidelines, indicating that a larger review of creased focus on brief (five to 30 minutes) psychosocial provider knowledge and national training materials and interventions for substance use and schizophrenia with po- guidelines could help ensure that all patients are receiving tential follow-up seems warranted and is supported by the best possible care. Giving nurses or medical assistants strong evidence from other settings.
more responsibility for follow-up medication administra- There are many reasons why a treatment regimen not ini- tion and regimen guidance could decrease the burden on tially indicated in evidence-based guidelines would be pre- the limited numbers of mental health specialists.
scribed in this setting: clinicians treat patients with complexsymptoms that may not always correspond to a single di- AUTHOR AND ARTICLE INFORMATION agnosis on the basis of Western-developed systems; many Dr. Wagenaar, Ms. Raunig-Berhó, Dr. Rao, Dr. Stergachis, and Dr. Sherr best-evidence treatments are not consistently (or ever) avail- are with the Department of Global Health, University of Washington,Seattle (e-mail: Dr. Wagenaar and Dr. Sherr able in Mozambique or in other similar LMICs; and the reality are also with Health Alliance International, Seattle. Dr. Rao is also of available financing, time, and information access to adopt with the Department of Psychiatry and Behavioral Sciences, and recent evidence-based guidelines is limited in Mozambique Dr. Stergachis is also with the School of Pharmacy, both at the and similar settings. For example, use of first-generation an- University of Washington, Seattle. Dr. Cumbe is with the Department tipsychotics by individuals with a primary diagnosis of a of Mental Health and Beira Central Hospital, Beira, Mozambique.
Dr. Kohrt is with the Department of Psychiatry and Behavioral Sci- substance-related disorder may make sense if these patients ences, Duke University, Durham, North Carolina. Dr. Napúa is with the have comorbid psychotic symptoms. In regard to the avail- Beira Operations Research Center, Beira, Mozambique. José Miguel ability of best-evidence treatments, methadone, buprenorphine, Caldas de Almeida, M.D., and Matt Muijen, M.D., Ph.D., are editors of acamprosate, naloxone, and disulfiram are all indicated to this column.
manage alcohol withdrawal or to reduce relapse, but none are This work was supported by the African Health Initiative of the Doris available in Mozambique. Finally, many psychiatric techni- Duke Charitable Foundation and the University of Washington's Royalty cians have been practicing since 1996 with few opportunities Research Fund. Dr. Sherr was supported by grant K02TW009207 fromthe Fogarty International Center.
for formal retraining as new formularies are adopted and The authors report no financial relationships with commercial interests.
evidence-based guidelines change. Going forward, formalevaluations of the psychiatric technician program, includingtraining, retraining, supervision structures, and effectiveness 1. Dos Santos PF: Evaluation of Mental Health Services in Mozambique of treatments provided, could drive quality improvements.
[in Portuguese]. Master's thesis. Lisbon, Portugal, New Univer-sity of Lisbon, Mental Health Policy and Services Department, Limitations. This study had limitations. First, our data lacked a gold-standard comparison diagnosis, impeding the de- 2. Wagenaar BH, Stergachis A, Rao D, et al.: The availability of es- termination of whether, for example, men are more likely sential medicines for mental healthcare in Sofala, Mozambique. GlobalHealth Action, 2015 (doi 10.3402/gha.v8.27942) than women to be given an epilepsy diagnosis or men are 3. Preux PM, Druet-Cabanac M: Epidemiology and aetiology of epi- actually presenting more often with epilepsy symptoms.
lepsy in sub-Saharan Africa. Lancet Neurology 4:21–31, 2005 Second, the reliability and validity of using the complex ICD-10 4. Bromet E, Andrade LH, Hwang I, et al: Cross-national epidemiology classification system in this setting are unknown and could of DSM-IV major depressive episode. BMC Medicine 9:90, 2011 be evaluated. Third, these data are from one hospital in 5. Ferrari AJ, Baxter AJ, Whiteford HA: A systematic review of the global distribution and availability of prevalence data for bipolar Mozambique and thus are likely not representative of di- disorder. Journal of Affective Disorders 134:1–13, 2011 agnostic and treatment patterns in rural areas or smaller 6. Baldessarini RJ, Pompili M, Tondo L: Suicide in bipolar disorder: risks and management. CNS Spectrums 11:465–471, 2006 7. Padrão P, Damasceno A, Silva-Matos C, et al: Alcohol consumption in Mozambique: regular consumption, weekly pattern and binge drinking. Drug and Alcohol Dependence 115:87–93, 2011 8. Chisholm D, Saxena S: Cost effectiveness of strategies to combat Psychiatric services at the Beira Central Hospital are currently neuropsychiatric conditions in sub-Saharan Africa and South East dominated by treatment for severe mental illness, most Asia: mathematical modelling study. BMJ 344:e609, 2012

Source: http://www.ddcf.org/globalassets/news-and-publications/2016-news-and-publications/16-0203-wagenaar_outpatient-mh-care_psychiatric-services.pdf