School of Public Health

Bradley H. Wagenaar

A systems approach to mental healthcare provision and suicide prevention in Sofala province, Mozambique

The studies within this dissertation describe existing patterns of outpatient, inpatient, and emergency room mental healthcare, suicide attempts and deaths due to suicide, and the availability of essential mental health medications, all within Ministry of Health clinics in Sofala Province, Mozambique. Specifically, this work: describes the real availability of essential medicines for mental healthcare (Aim 1); describes trends in mental healthcare utilization and health facility determinants of diagnosis patterns (Aim 2); analyzes current outpatient and inpatient diagnosis and treatment patterns, along with who is at risk for common diagnoses (Aim 3); and describes the basic epidemiologic profile of emergency room psychiatric visits, suicide attempts, and deaths due to suicide, as well as methods used in suicide attempts or deaths (Aim 4).

In Aim 1 we found that essential medicines for mental health were routinely unavailable. No atypical antipsychotics existed at any clinics and essential typical antipsychotics were haphazardly available. Further, no selective serotonin reuptake inhibitors (SSRIs) were readily available, which is concerning as they are essential for treatment of individuals with underlying cardiovascular disease and/or suicidal ideation. We recommend prioritizing the availability of at least one SSRI, one atypical antipsychotic, and consistent availability of selected typical antipsychotics.

In Aim 2 we found that outpatient mental health utilization is increasing, but currently mostly focuses on epilepsy and schizophrenia/delusional disorders. Women appear more likely to present for neurotic/stress-related conditions (12.8% of consults for women, 5.7% for men, p<0.001), while men appear 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. Due to diagnostic or utilization differences, rural clinics may be missing important cases of organic, substance-use, schizophrenia, and mood disorders.

In Aim 3 we found that current patterns of medication usage may not follow international evidence-based guidelines. This was especially prominent around the potential overuse of typical antipsychotics and the anticholinergic agent promethazine for movement side-effects. Utilization was most common for schizophrenia (37.4% of consultations), epilepsy (15.9%), delirium (6.9%), and organic behavioral disorders (2.7%). Most disorders had few new patients entering the care system, which argues for innovative efforts to broaden care beyond severe mental disorders. These findings can help target potential modifications to national treatment guidelines and essential drug lists.

In Aim 4 we found that females were more likely to present with suicide attempts, but that deaths due to suicide were more often male. Females often employed less lethal suicide methods, such as toxic substances, whereas males used lethal methods, such as hanging. Over 65% of suicide attempts used rat poison. Approximately 54% of deaths due to suicide used a toxic substance, with the singular most common being rat poison (28% of deaths). Given these findings, policies to reduce the availability and toxicity of rat poison and other common suicide methods should be considered.

We aim for this work to inform the development of evidence-based mental health policy, along with additional population and systems-level studies on mental ill-health and suicidal behavior in Mozambique and other similar countries.