A retrospective descriptive observational study was performed with a quantitative approach. The survey was carried out at the Psychiatry Outpatient Clinic of Hospital de Base, located in the municipality of São José do Rio Preto, São Paulo, Brazil. As a public psychiatric outpatient clinic that receives psychiatric patients from the northwest of São Paulo State, it is possible to draw a specific picture of the region. The clinic offers multidisciplinary treatment for people with psychotic disorders, depression, anxiety, post-traumatic stress disorder, mood disorders, schizophrenia, and sexuality problems and for drug users, and child psychiatry care, in addition to carrying out general screening to refer patients for other therapies. The services offered are part of a treatment reference center of the Brazilian NHS (SUS) with patients being referred for diagnosis, monitoring, and mental health treatment. The patients come from a region that comprises 102 municipalities with more than 2 million inhabitants under the administration of the Regional Health Department XV (DRS XV) based in São José do Rio Preto, São Paulo state, Brazil (Figure 1).

The electronic medical records of patients who consulted in the psychiatry outpatient clinic of a teaching hospital, Hospital de Base, São José do Rio Preto, SP, Brazil, between March 2018 and March 2020 were reviewed. Data on psychiatric-related problems as itemized in the International Classification of Diseases—10th Edition (ICD-10), number of appointments, and prescribed treatments were collected. All patients with psychiatric disorders and with at least one appointment in the study period were included. Eight aspects were investigated: 1—disorder classification; 2—patient gender; 3—patient age; 4—patient origin; 5—symptoms at the last appointment; 6—number of medications prescribed at the last appointment; 7—illness duration; and 8—treatment duration. Patients who did not have any consultation for psychiatric care within the study period were excluded. These variables were chosen to characterize the main components listed in the MVPEP^® program of electronic medical records used by the Specialty Outpatient Clinic. This study was approved by the Research Ethics Committee of the Medical School of São José do Rio Preto (FAMERP) under registration number 4.040.192. Patients’ identities have all been kept confidential. Due to the retrospective nature of the study with data being collected from the hospital’s electronic medical records, patients enrolled in this study were not required to sign an informed consent form.

The data were organized in a spreadsheet and examined using Microsoft Office Excel 2010® software. The data were analyzed using descriptive statistics including absolute and relative frequencies and means and standard deviations. In addition, the chi-square and Fisher’s exact tests were used for comparisons using GraphPad Instant Software (Version 3.06). Multivariate logistic regression, used to verify the main diagnoses found and related treatment, was performed with the SPSS Program (IBM, version 23). Student’s t-test was used to evaluate differences in gender related to disease duration, whereas analysis of variance (ANOVA) was used to assess differences in the mean duration of the different types of disorders and the frequency of worsening of symptoms.

Epidemiological surveys carried out by the Health Ministry have found a 20% prevalence of mental disorders in the adult population: 3% of the general population suffer from severe and persistent mental disorders, 12% need some ongoing or occasional mental healthcare, and 6% have severe psychiatric disorders resulting from the use of alcohol and other drugs. Currently, only 2.3% of the Brazilian NHS annual budget is allocated to Mental Health (8). The incidence of these disorders in public health service users was reported in a recent multicenter study involving four Brazilian state capitals. The rate was above 50%; it was especially high among women, the unemployed, and people with little education and low income (9–11). These results place Brazil as one of the countries with the highest number of anxious people in the world, demonstrating a high prevalence of mental disorders in the Brazilian population (12, 13). Refining the profile of these patients is detrimental to the promotion of more effective public mental healthcare policies and treatment. Furthermore, as a critical factor, research has shown the presence of common mental disorders (states of psychological distress, anxiety, depression, or somatoform symptoms that formally do not meet sufficient criteria for diagnoses of depression and/or anxiety according to the current classifications) manifesting together, increasing psychiatric comorbidity (13–15). These analyses highlight women with an average age of 53 years who require continuous or occasional mental healthcare associated with depression and anxiety as a predictor of greater vulnerability to mental disorders. However, the male gender was associated with more serious disorders such as schizophrenia as well as delusional disorder, alcohol abuse, and abuse of illicit substances.

There is a paucity of studies and reference services in the field of mental health in the northwest region of São Paulo State. Detailed assessments are required regarding the regions covered by the service and the profile of the user served. Santos et al. (17) demonstrated that the outpatient model adopted by Dr. Jandira Masur Psychiatric Specialties Medical Outpatient Clinic in Vila Maria, São Paulo, is a reference in the management of mental health in the Brazilian NHS (17). The patients treated at this center are mostly women (62%), and the prevalent diagnoses are mood and anxiety disorders (36.5%), followed by stress-related disorders (29%) (17, 18). The findings in the current study demonstrate some clinical characteristics similar to the profile presented by this center. This indicates that coordination between the entire network of continued healthcare and the outpatient model can offer a greater comprehensiveness of mental healthcare (17–19).

The discussion about outpatient mental healthcare has recently taken other paths. The work carried out in these lines of action does not receive the necessary attention within the scope of public policies with a lack of knowledge regarding this model being demonstrated (19, 20). The Brazilian Psychiatry Association proposes the creation of services that more specifically meet the needs of the Brazilian population. The results of this study also suggest the necessity of the insertion of specialized outpatient clinics within the same debate as Psychosocial Care Centers (CAPS), the Family Health Strategy (ESF), psychiatric beds in general, and matrix support hospitals in Brazil (19–21). The fact that many disorders presented by the patients in the current sample are characterized by a chronic evolution, multidrug treatment and instability in the manifestation of symptoms, and treatment adherence indicates that many cases require continuous care due to more serious and persistent disorders, while less serious disorders require sporadic care. The reorganization of a network of services replacing the psychiatric hospital often includes a role for outpatient clinics (22–25).

There was a predominance of women with anxiety and depressive disorders with 78.86% of patients in the group of generalized anxiety being women. However, many patients present multiple conditions—anxiety and depression, or schizophrenia and bipolar disorder, for example, and there seems to be a tendency for these patients to present more than one diagnosis. Periods of control and remission of symptoms in these profiles are related to effective psychiatric monitoring associated with psychotherapy, psychoeducation programs, family therapy, home visits, occupational therapy, skill development, monitored medication, rehabilitation programs, self-help groups, and therapeutic monitoring, among others (25–29). The provision of specific services for realities like these contributes by improving the quality of mental healthcare and can dialog with the clinical perspective (27–29).

Clinical and epidemiological research has reformulated the work in these outpatient clinics based on a clinical perspective (30). One of the main changes was the inclusion of psychologists (30, 31). The majority of these professionals concentrated on health programs for HIV, hypertension, smoking, and diabetes, among others (30). It has been recommended that any suffering patient, regardless of their diagnosis, symptoms, age, gender, or even psychopathology, should have access to an expanded clinic and should be welcomed within the scope of mental health (30–32). This was substantial progress and resulted in the arrival of many untreated or poorly treated patients, whose psychological impairment had serious consequences on their daily lives (30). The impact of this practice reinforced the need for an increase in hiring human resources and indicated gaps in the way psychiatric treatment was being offered in outpatient clinics (with its focus on the clinical characteristics of pharmacotherapy) (30–33).

Studies on these practices have focused on the outpatient context (33). Regular meetings were established with teams, encouraging collaboration and communication among mental health professionals, and continually working together to receive clients in the form of the reception group (33, 34). The group of professionals was extended beyond psychiatrists and psychologists, with nurses, social workers, and occupational therapists being available in certain units (34, 35).

Santos et al. (17) highlight the importance of discussions in mental health forums from this standpoint (17, 18). They defined the mental health outpatient clinic as a legitimate clinical device in the care network, not only in cases considered mild or moderate but also in severe cases (17, 18, 34). This resizing represents a milestone as it serves as the basis for the new guidelines as reported in the document entitled Recommendations on Mental HealthCare in the Basic Network (36).

Data from the World Health Organization (WHO) indicate that during the years of the COVID-19 pandemic 93% of countries around the world have experienced some type of outage in mental health services (37). During this period, outpatient clinics specialized in mental health used information from international and national health authorities to make decisions to adapt standards and routines in units, providing data on the clinical profile of patients treated before and after the start of the pandemic (17, 38, 39). Furthermore, modifications described based on management reports, procedure manuals, minutes of meetings, and training presentations made it possible to maintain outpatient care during this period (17). The findings of the current study indicate similar characteristics. Of the consultations analyzed here, 65.2% (n = 5,466) took place via telemedicine and online assessments. In fact, the data collection period for the present sample was also affected by the COVID-19 pandemic as it included 1 year of lockdown. Different prevalences and factors emerged in this context. Global literature indicates that the epidemiological distribution of mental disorders and associated factors was heterogeneous in the general public, COVID-19 patients, and healthcare professionals (38, 40–42). The advantages of telemedicine in this situation are well documented; however, this modality may require greater skill of psychologists and psychiatrists, and more dialog between these and other professionals, as assessments are essentially clinical and may depend on interactionist factors at the time of evaluation (42, 43). Furthermore, evidence suggests that a psychiatric epidemic is occurring as a consequence of the pandemic and that clusters of symptoms such as those found in the current sample may be due to this situation (40, 41). Arafat et al. reported that situations of this order in telemedicine care used in the treatment of critical mental health issues still need to be precisely explored, especially with regard to diagnosis and its association with clinical symptomatological and sociodemographic characteristics (42).

These studies have demonstrated that there is a gap between cases with a very long duration of illness and treatment and newly diagnosed and treated cases with the same prevalent symptoms (sadness, anxiety, and irritability) (44). Similar to international reports (45, 46), this study also identified the predominance of anxiety and depressive disorders in women: 78.86% of the group with generalized anxiety were women. However, many patients had multiple conditions—anxiety and depression, for example, making them more likely to have more than one diagnosis. These data reinforce the need to implement a new mental healthcare model in Brazil, especially after the COVID-19 pandemic, based on the installation of a mental healthcare model guided by the psychosocial paradigm, which is directed toward the clients in their various dimensions within a socio-community context (47, 48). The RAPS proposal foresees the development of intersectoral actions and encourages the active participation of users who were unable to access mental health services that were not provided by CAPS, or who were not contemplated for comprehensive care beds or residential therapeutic services (SRT) (16, 49, 50). It also provides for the development of innovative care practices with the active participation of users (16, 49, 50).

Epidemiological reports on mental health from the last decade played a significant role in the creation of RAPS as an organizational proposal for mental health services in Brazil (49). The clinical profile and sociodemographic characteristics highlight the shared and interdisciplinary accountability of cases as an element capable of influencing hierarchical, pyramidal, and fragmented patterns and promoting continuous flows of care in appropriate technological spaces (13, 51). As a result, there was a reversal of spending on mental health with financial stimulation for substitute services, the closure of psychiatric beds in monovalent hospitals, and the expansion of community services (49).

The challenge for improving this model is to identify which populations are most in need and strengthen intersectoral coordination (13, 52, 53). Diagnostic practices need to establish mechanisms that encompass symptom profiles that are widely shared across populations and disorders (with regard to psychopathology), but others are more specific to one or a set of forms of psychopathology (53–55). The severity of symptoms and treatment time in certain regions may indicate the need for specific services for certain locations (54–56). As an example, the current sample indicated that diagnosis and treatment time are related, thereby reinforcing the need for a biopsychosocial model. The findings of this study revealed an average treatment time of 9.65 ± 10.40 years for women and 8.87 ± 9.14 years for men. The most common disorder that also had the longest treatment time was BAD (current hypomanic episode); with a mean of 28.91 years, it is associated with symptoms such as sadness, anxiety, and irritability (Figure 4). The moderate depressive episode at 9.96 years persisted for the shortest time. These characteristics represent more difficult sectoral demands as they are directly related to international nosologies (53–57).

There is a discussion about the need to improve the diagnosis (57, 58). The search for biomarkers has received increasing attention from the scientific community as it may help to establish more effective public policies in mental health (58). Research is moving toward the idea that perhaps there is a general dimensionality of predisposition in the psychic and biological patterns of disorders (58–61). However, these results still need to be officially organized.

The challenge for the assumption of dimensionality is to identify what the main reference dimensions are and quantify them with respect to the population. In this model, two patients who present the same symptoms, but different sets of mutations or psychoneuroimmunological patterns, could be diagnosed and treated differently (Figure 6). It is also necessary to verify whether a single dimension is capable of measuring psychopathology, its comorbidity, the severity of symptoms, and its response to treatment over time (59, 60). In practice, the community perspective implies the development of this scale across a wide range of services, contexts, and locations. This process, which has not yet begun in many regions and countries, aims to ensure that some of the functions of mental institutions are fully provided and that stereotypes of patients in psychological distress are not perpetuated (61–76).

As a descriptive retrospective observational study carried out using electronic medical records, this research identified small data errors, with some incomplete and/or missing information. This is an important factor and can increase the difficulty in analysis. Some records did not present a detailed longitudinal analysis of patients, such as the presence or absence of adverse events during treatment, higher levels of social vulnerability, and greater history of mental disorders in the family and cultural variables. These factors may represent common precedents for the etiology and development of disorders and serve as a basis for new epidemiological analysis in mental health (69–76).