Outpatient visits for psychiatric disorders in Peru: a nationwide analysis using administrative data

Consultas ambulatorias psiquiátricas en el Perú: un análisis a nivel nacional

Esta obra está bajo una Licencia Creative Commons Atribución 4.0 Internacional.

The World Health Organization (WHO) has recently stated that no health or sustainable development can be achieved without mental health (1). In addition, psychiatric disorders are now recognized as major causes of morbidity, burden of disease, and health costs (1,2,3). In 2019, major psychiatric disorders (mainly anxiety and depression) accounted for 970 million cases, increasing by half the number of cases in 1990 (2,3). Similarly, the number of disability-adjusted life-years (DALYs) attributable to psychiatric disorders have raised from 81 million to 125 million during the same period (2,3), the latter representing 1 out of 5 DALYs globally (1). In this line, global (e.g., WHO) and regional (e.g., Pan American Health Organization) organizations have launched initiatives to promote and increase the access to mental health care and thus, reduce the consequences of psychiatric disorders (e.g., suicide mortality) (1,4,5). Hence, metrics that focus on mental health care (e.g., outpatient visits) could help to tailor mental health strategies, specially across low- and middle-income countries (LMICs) like Peru.

Characterizing the frequency of psychiatric disorders at the outpatient setting has several benefits because it measures the utilization of health care services (6). From the healthcare system perspective, characterizing the population that visits health services due to psychiatric disorders is important for health services planning (7). From the public health perspective, characterizing the frequency of psychiatric disorders at the outpatient setting pinpoints which psychiatric disorders impose most of the psychiatric outpatient burden in the Peruvian health system and thus, where mental health policies should be directed. Furthermore, it is unknown whether and how much the COVID-19 pandemic and lockdown affected the flow of psychiatric outpatient visits in Peru, which is important to guide the Peruvian health system response to the ongoing and future global or local health emergencies.

To provide evidence of the national frequency and monthly trends of psychiatric disorders in the outpatient setting of Peru, we analysed outpatient morbidity registries between 2018-2021. This information is important for both national and subnational organizations working on mental health policies in Peru and other LMICs to guide the development of preventive strategies and the allocation of resources. Furthermore, to highlight subnational inequalities in the level of healthcare utilization for psychiatric disorders, we also described the number of psychiatric outpatient visits in relation to population at the province level. This evidence could help to track progress towards the already launched Peruvian Mental Health Law, which seeks for universal mental health coverage in Peru (8).

Between 2018 and 2021, a total of 3,062,618 outpatient visits were due to psychiatric disorders in Peru, which represented 2.3% of all outpatient visits (Table 1). The proportion of all visits that were for any psychiatric disorder increased slightly from 2018 (2.0%) to 2021 (2.8%). Out of all outpatient visits destined for psychiatric disorders in 2018-2021, 54.7% were in women and 58.2% were in those aged 15-64 years (i.e., working age). Stratified by HCF levels, 39.6% and 39.0% of all outpatient visits for psychiatric disorders took place in secondary and tertiary HCFs, respectively. Half of the outpatient visits for psychiatric disorders (50.7%) took place in MINSA HCFs. The 48.5% of all psychiatric outpatient visits took place in Lima, whereas only 0.2% took place in Madre de Dios.

Table 1.
Characteristics of the study population by year

National frequency of psychiatric disorders in outpatient care

Between 2018-2021, there were little variations in the relative contribution of specific groups of psychiatric disorders to the total outpatient burden for psychiatric disorders (Figure 1); nonetheless, the psychiatric outpatient burden differed by sex and age. The absolute number of psychiatric outpatient visits shifted from men in younger age groups to women in older age groups; for example, in 2019, 65.7% of all psychiatric outpatient visits in those aged <15 years were in men, whereas only 36.1% of all psychiatric outpatient visits in those aged ≥65 years were in men (Figure 1).

Figure 1.
Outpatient visits by groups of psychiatric disorder, sex, and age groups, 2019

Results for 2018, 2020, and 2021 are presented in Supplementary Figures 2-4. Similar figures but showing the proportion of visits above all psychiatric visits for each psychiatric disorder are shown in Supplementary Figures 5 (overall) and 6-8 (stratified by HCF level).

In the working age groups (i.e., 5-year age groups between 15-64 years), most psychiatric outpatient visits were destined for anxiety disorders regardless of sex; of note, the proportion of all psychiatric visits destined for anxiety disorders increased with older age groups and was higher in women (~40-47% in 2019) than men (~30-33% in 2019). The psychiatric disorder that accounted for the second highest number of psychiatric outpatient visits in the working age groups varied by sex; in 2019, they were schizophrenia spectrum disorders in men (except in those aged 15-19 years) and depressive disorders in women. The proportion for depression disorders decreased with older age groups in women but increased with older age groups in men >35 years; across working age groups, proportions were consistently higher in women (~22-26%) than men (~10-14%). Notably, the proportion for organic mental disorders peaked in those aged >65 years (29.2% in men and 24.5% in women; 2019).

In general, the same relative frequency of psychiatric disorder groups was observed when stratified by HCF levels. Nonetheless, schizophrenia spectrum and bipolar disorders were most frequent in tertiary HCFs, whereas anxiety and sleep related disorders were most frequent in primary and secondary HCFs.

Monthly trends of the number of outpatient visits of psychiatric disorders

We observed monthly variations in the absolute number of visits for the combined group of psychiatric disorders and the three psychiatric disorders with the highest number of visits (i.e., anxiety, depressive, and schizophrenia spectrum disorders) before the COVID-19 pandemic (2018-2019). Nonetheless, there were no monthly differences in the proportion of psychiatric visits for each of the three psychiatric disorders above mentioned. The monthly average of outpatient visits in 2019 was 80,391 for all psychiatric disorders, 21,339 for anxiety disorders, 11,396 for depressive disorders, and 7,456 for schizophrenia spectrum disorders (Figure 2). For the combined group of psychiatric disorders and the three psychiatric disorders with the highest number of outpatient visits (i.e., anxiety, depressive, and schizophrenia spectrum disorders), we observed two peaks in the absolute number of outpatient visits in 2019. The first peak began in February and peaked in April/May, while the second one began and peaked in September.

Figure 2.
Monthly trends of the absolute number of outpatient visits for all psychiatric, anxiety, depressive and schizophrenia spectrum disorders, 2018-2020

Results by HCF levels are presented in Supplementary Figure 9. Results for the rest of psychiatric disorders are presented in Supplementary Figure 10. We only included results for 2018, 2019, and 2020 for better data visualization

The monthly average of outpatient visits in 2020 was 40,098 for all psychiatric disorders, 11,897 for anxiety disorders, 6,144 for depressive disorders, and 3,999 for schizophrenia spectrum disorders; these were significantly lower than the monthly average of outpatient visits in 2019 (p<0.05 for all and each psychiatric disorder) and 2018 (p<0.05). In March-April 2020 (i.e., after the beginning of COVID-19 lockdown in Peru), we observed a sharp decrease in the absolute number of monthly outpatient visits for all, anxiety, depressive and schizophrenia spectrum disorders compared with January-February 2020 and March-April 2019 (Figure 2); this finding was consistent in all HCF levels and the rest of psychiatric disorders. In March and April 2020, the absolute number of outpatient visits for all psychiatric disorders dropped by 65% and 90% compared with March and April 2019, respectively. This finding was consistent across all specific groups of psychiatric disorders.

Since May 2020, the absolute number of monthly outpatient visits for all, anxiety, depressive and schizophrenia spectrum disorders heavily increased; after October 2020, it even surpassed the absolute numbers of visits in 2019. After June 2020, the proportion of psychiatric visits above all outpatient visits slightly increased and surpassed the proportions in previous months (e.g., 3.1% in September 2020 vs 1.9% in March/April 2020) and in 2019 (e.g., 1.7% in September 2019).

Subnational frequency of psychiatric disorders in outpatient care

At the province level, there was high variability in the number of psychiatric visits relative to the province population (Figure 3). The provinces with the highest psychiatric outpatient visits per 10,000 population were mainly in the Coast, whereas provinces with the lowest numbers were in the Highlands; this finding was consistent across years, although visits per 10,000 population decreased in most provinces in 2020 and 2021. In regions with both Coast and Highlands areas, psychiatric outpatient visits per 10,000 population decreased from the Coast to the Highlands; for instance, in 2019, in the Ancash region, Santa had the highest outpatient visits per 10,000 population (425; Coast), whereas Antonio Raymondi had the lowest outpatient visits per 10,000 population (7; Highlands); that is, although both provinces are in the same region (~170 km apart), the visits per 10,000 population were 60 times higher in Santa the coastal locality.

Figure 3.
Number of outpatient visits for psychiatric disorders per 10,000 people, 2019

Results for 2018, 2020, and 2021 are presented in Supplementary Figure 12

At the province level, there was a moderately positive correlation between the number of psychiatric outpatient visits per 10,000 population with HDI (p<0.05), yet a moderately negative correlation with the proportion of people living in poverty (p<0.05) and in rural areas (p<0.05) (Supplementary Figure 13).

Leveraging on a nationwide registry of ambulatory visits, we have provided the first national and subnational estimates of the frequency of major psychiatric disorders in the outpatient setting from Peru. In so doing, we found that half of outpatient visits for psychiatric disorders took place in the capital of Peru (Lima), which hosts a third of the Peruvian population and encompasses 37% of all HCFs (17). Also, across working age groups, from all outpatient visits for psychiatric disorders, those destined for anxiety/depressive disorders represented approximately 6 out of 10 visits in women and 4 out of 10 visits in men. Monthly trends of the major psychiatric disorders in outpatient care during the pre-pandemic period in Peru showed 2 peaks in the absolute number of outpatient visits: April-May and September. After the beginning of lockdown, the absolute number of monthly outpatient visits for the major psychiatric disorders dropped by more than a half (compared to 2019) but increased after May 2020. After three months of lockdown, the proportional contribution of psychiatric visits to the total outpatient burden started to increase. When analysing subnational trends, provinces in the Highlands had lower psychiatric visits per 10,000 population compared to Coastal provinces.

Public health relevance

Our results indicate which psychiatric disorders are the most important drivers of the burden of outpatient visits in Peru. This finding has relevant implications in Peru and similar countries (e.g., Andean Latin America) from a public health perspective, as it informs decisions from local health authorities working on mental health policies. As anxiety/depressive disorders represent most outpatient visits for psychiatric disorders in Peru, mental health policies should guarantee the inclusion of health service planning strategies for depression and anxiety, such as increasing the availability of appointments for mental health counselling and increasing the number of options for pharmacological treatment. Furthermore, even though local clinical guidelines for depressive and schizophrenia spectrum disorders are available (18,19), there is a need for clinical guidelines for anxiety disorders adapted to the Peruvian population.

As mentioned above, in 2018 and 2019, the absolute number of monthly outpatient visits for the major psychiatric disorders in Peru (i.e., anxiety, depression, and schizophrenia spectrum disorders) peaked in April-May and September. In this line, HCFs in Peru should be prepared to receive more psychiatric visits during these periods. For example, they could increase the availability of psychiatric drugs, increase the number of mental health workers, and restructure schedules to minimize contact among outpatients (according to current COVID-19 guidelines). Furthermore, as the number of people living with psychiatric disorders is expected to increase because of population growth (2), other general measures could also help to reduce the burden of psychiatric outpatient visits, like offering mental health services virtually or at the patient’s home and implementing electronic medical records (20,21).

We observed large subnational differences in the psychiatric outpatient visits per population; in particular, provinces in the Highlands had lower psychiatric outpatient visits per 10,000 people than Coastal provinces. This finding calls for urgent actions to improve the access to mental health care in Peru, particularly in the Highlands. The latter is currently endorsed by the Peruvian Mental Health Law, which seeks to guarantee the universal access to mental health care in Peru (8). People living in the Highlands are often poor (e.g., 50.4% of poverty in rural Highlands) and live in rural areas (e.g., 60% of rurality in Huancavelica, a region crossed by the Andes) (22,23). Considering that people living in poverty and rural areas are less likely to seek mental health care (24), this could result in a lower number of outpatient visits for psychiatric disorders. This is consistent with our ecological analysis at the province level, which shows that provinces with low HDI and high levels of poverty and rurality had lower psychiatric outpatient visits per 10,000 people. Of note, these differences could also be attributed to the lower number of healthcare workers and HCFs in Highland provinces (25), as well as the strong stigma regarding mental disorders and registry underreporting that exists in the Highlands (26).

Results in context

We have provided the first national evidence of the burden of different groups of psychiatric disorders in the outpatient setting in Peru. Our study is uniquely positioned to inform clinicians and public health authorities from Peru and countries with similar profiles on their health system and frequency of psychiatric disorders, which is relevant to plan healthcare delivery at the outpatient setting.

Our results indicate an abrupt decrease in the number of psychiatric outpatient visits across all HCFs during the first months of the COVID-19 pandemic in Peru (March/April 2020), which corresponds to the beginning of the strict lockdown period established by the Peruvian Government (27). Other countries have also reported an important reduction of the number of outpatient visits during the COVID-19 pandemic. In Brazil, there was a 28% decrease in the number of mental health outpatient visits, yet an increase in the number of mental health emergency visits (28). At a South Korean hospital, there was a 13.1% reduction in the number of mental health outpatient visits compared to the number before the pandemic (15). At the largest admitting psychiatric facility in the capital city of the United Arab Emirates, there was a 20-30% drop in the total number of outpatient visits and an 80% drop-in new appointment visits in the early months of the pandemic (29). At a public health service specifically dedicated to vulnerable groups in Italy, there was nearly a 35% drop in the number of mental health outpatient visits in March 2020 (i.e., lockdown period in Italy) in contrast to the number of visits in March 2019 (30). On the other hand, during the COVID-19 pandemic surge in Massachusetts (USA), there was a 9.1% increment in the number of outpatient visits for mental health/substance use disorders relative to the pre-pandemic period (31).

Anxiety and depressive disorders represent most psychiatric outpatient visits in Peru. This is consistent with the fact that anxiety disorders and affective disorders are the mental diseases with the highest twelve-month prevalence in the general population of Peru and South America (32). Furthermore, this could also be explained by the fact that people with anxiety/depressive disorders often require regular appointments, especially in early months of their treatment. It should be noted that the COVID-19 pandemic could have affected the prevalence of psychiatric disorders. A population-based study in Peru showed an increase in the prevalence of anxiety and affective disorders after the COVID-19 lockdown, which could explain in part our findings regarding the increase of the number of psychiatric outpatient visits after May 2020 (33,34).

Strengths and limitations

The information about the frequency of differentoutpatient groups of psychiatric disorders at thenational and subnational level in Peru, obtained from acareful examination of a nationwide registry is usefulfor clinicians and public health authorities in Peru andLatin America. Nonetheless, our study has some limitations. First, although the registry has national coverage, there could be an under-representation of psychiatric visits in the outpatient setting because of two reasons: 1) As the registry herein analysed aggregates monthly visits reported by every HCFs in Peru, it is possible that some HCFs may have not reported any data, or they are delayed in reporting their estimates; and 2) There could have been errors during the data entry or ICD-10 codification. As the data we used only registers one diagnosis for each individual attention and diagnosis could be adjusted to treatment, there could be underreporting of other psychiatric diagnoses. Because of this, the absolute number of psychiatric visits could be higher and therefore, our results show a conservative scenario. Conversely, data entry errors could have also inflated our results if non-psychiatric diagnoses were coded as psychiatric disorders.

Second, we lacked other covariates to describe the psychiatric outpatient visits; this limitation is inherent to the outpatient registry. For example, had we known the mode of visit method (in-person vs telemedicine), we could have estimated what proportion of all psychiatric outpatient visits was performed using telemedicine; the latter could have been useful to describe how Peruvian HCFs changed their method of delivering outpatient visits during the pandemic (i.e., using more telemedicine).

Psychiatric disorders represent a small fraction of the outpatient visits in Peru, out of which anxiety and depressive disorders remain the most frequent, especially across working age groups. Mental health policies from national and subnational organizations in Peru are needed to tackle the psychiatric outpatient burden, considering demographic and subnational differences, monthly trends, and the COVID-19 pandemic.

This analysis used open-access data that do not contain personal identifiers. Therefore, we did not seek approval by an Ethics Committee and consent was not required. The opinions presented in this work are those of the authors alone, and do not necessarily represent those of the institutions to which they belong. The authors are collectively responsible for the accuracy of the findings presented.

https://revistas.upch.edu.pe/index.php/RNP/article/view/5183/5486 (pdf)

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