title: Health facility determinants and trends of ICD-10 outpatient psychiatric consultations across Sofala, Mozambique: time-series analyses from 2012 to 2014.
abstract: BACKGROUND
  Few peer-reviewed publications have taken a longitudinal or systems approach to mental healthcare (MH) utilization in low- and middle-income countries. We analyzed: (1) outpatient ICD-10 diagnoses over time and by gender; and (2) health facility determinants of MH service utilization.
  
  
  METHODS
  We reviewed a census of 15,856 outpatient psychiatric consultations conducted at Ministry clinics in Sofala province, Mozambique from January 2012-June 2014. Generalized estimating equations were used to model facility determinants of ICD-10 diagnoses.
  
  
  RESULTS
  Across the period, 48.9 % of consults were for epilepsy, 22.4 % for schizophrenia/delusional disorders, and 8.8 % for neurotic/stress-related disorders. The proportion of schizophrenia/delusional disorders has decreased over time (32 % in 2012; 13 % in 2014, p = 0.003), in favor of greater diversity of diagnoses. Epilepsy has increased significantly in absolute and proportional terms. Women are more likely to present for neurotic/stress-related conditions (12.8 % of consults for women, 5.7 % for men, p < 0.001), while men are more likely to present for substance use (1.9 % for women, 6.4 % for men, p < 0.001). Clinics with more psychiatric technicians have a 2.1-fold (CI: 1.2, 3.6) increased rate of schizophrenia/delusional disorder diagnoses. Rural clinics saw a higher proportion of epilepsy cases and a lower proportion of organic, substance use, schizophrenia, and mood disorder cases.
  
  
  CONCLUSIONS
  Outpatient MH service provision is increasing in Mozambique, although currently focuses on epilepsy and schizophrenia/delusional disorders. Mid-level psychiatric providers appear to be associated with a higher proportion of schizophrenia/delusional disorder diagnoses. Due to diagnostic or utilization differences, rural clinics may be missing important cases of organic, substance use, schizophrenia, and mood disorders. Models and decision-support tools for mental healthcare integration with primary care practice are needed in Mozambique to allow further scale-up of mental health services.
authors.affiliation: Department of Epidemiology, University of Washington School of Public Health, 1959 NE Pacific Street, Seattle, WA, 98195, USA. wagenaarb@gmail.com.|Health Alliance International, Seattle, Washington, USA. wagenaarb@gmail.com.
authors.forename: Bradley H
authors.initials: BH
authors.lastname: Wagenaar
authors.affiliation: Department of Mental Health, Ministry of Health, Sofala Provincial Health Directorate, Beira, Mozambique. vcumbe@gmail.com.|Department of Psychiatry, Beira Central Hospital, Beira, Mozambique. vcumbe@gmail.com.
authors.forename: Vasco
authors.initials: V
authors.lastname: Cumbe
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA. mj.raunig@gmail.com.
authors.forename: Manuela
authors.initials: M
authors.lastname: Raunig-Berhó
authors.affiliation: Department of Global Health, University of Washington, Seattle, WA, USA. deeparao@uw.edu.|Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA. deeparao@uw.edu.
authors.forename: Deepa
authors.initials: D
authors.lastname: Rao
authors.affiliation: Beira Operations Research Center, Ministry of Health, Beira, Mozambique. mnapua@hotmail.com.
authors.forename: Manuel
authors.initials: M
authors.lastname: Napúa
authors.affiliation: Department of Biostatistics, University of Washington, Seattle, WA, USA. jphughes@uw.edu.
authors.forename: James P
authors.initials: JP
authors.lastname: Hughes
authors.affiliation: Health Alliance International, Seattle, Washington, USA. sherr@uw.edu.|Department of Global Health, University of Washington, Seattle, WA, USA. sherr@uw.edu.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sherr
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data; D003156:Community Mental Health Services / Q000706:statistics & numerical data*; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D038801:International Classification of Diseases; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology / Q000628:therapy*; D009073:Mozambique / Q000453:epidemiology; D010045:Outpatients / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012423:Rural Health / Q000706:statistics & numerical data; D017678:Sex Distribution; D014504:Urban Health / Q000706:statistics & numerical data