Introduction
One in 27 people with depression, the second largest contributor to global disability, receives minimally adequate care mental health services in low- and middle-income countries (LMIC) [
1,
2]. Integrating evidence-based mental health services into primary care and other existing health service delivery platforms has been recognized and implemented as a leading strategy for reducing the gap between burden and available mental healthcare in LMIC [
3‐
7].
Addressing the mental health treatment gap is integral to achieving goals for sustainable development set by the United Nations [
8], particularly that of universal health coverage [
9,
10]. Universal health coverage is defined by two dimensions: that all people should receive needed healthcare (i.e., service coverage), and those who do receive care should not suffer financial hardship as a result (i.e., financial protection) [
11]. The latter presents a challenge to health delivery systems primarily structured on individual out-of-pocket (OOP) expenditure to finance service provision, which represents a regressive form of health system financing [
12]. Costs to the health system are also of paramount importance to healthcare administrators and policy makers when considering which health innovations to scale up and include as part of essential healthcare packages [
13]. As such, researchers must examine the financial and economic impact to individuals and health systems when implementing and scaling up novel approaches to mental health services.
Some evidence from high-income countries indicates treatment for depression can improve economic outcomes, including reduced healthcare costs, though the evidence is not conclusive [
14]. Research is sparser on the effects of services for depression in LMIC. A recent meta-analysis found an unconditional average effect size of 0.22 standard deviations for mental health interventions across all economic outcomes, with the smallest effect sizes observed in low-income countries [
15]. Longitudinal evidence is also needed to more adequately understand the effects of services for depression on healthcare costs, particularly within LMIC [
16].
Depression and other mental disorders are associated with increased healthcare costs to service users and health systems in both high- and low-resource settings [
17‐
20]. A 2020 meta-analysis found adults with depression have approximately 160% greater costs than the general public, primarily resulting from direct healthcare costs and lost productivity [
19]. In Ethiopia, households of individuals with depression are more likely to experience catastrophic OOP expenditure and impoverishment resulting from increased healthcare use [
17]. Repeat household surveys indicated depression severity is associated with both increased healthcare use and OOP expenditure among community members in Chitwan District, Nepal, where the present study took place [
21]. In South Asia, mental health problems are often expressed through physical symptoms, such as head and body aches, numbness, weakness, and exhaustion [
22‐
24]. Moreover, depression is linked to diabetes, hypertension, cardiovascular disease, and other co-occurring physical health conditions [
25]. Therefore, health service researchers have typically included healthcare costs and use for both physical and mental health concerns when working South Asian contexts, such as in the repeat household surveys above [
21].
The Programme for Improving Mental Health (PRIME) was one of the largest research initiatives to implement an integrated task sharing approach to expand access to mental healthcare in LMIC [
26]. PRIME implemented a multi-level district mental healthcare plan in five countries – Ethiopia, India, Nepal, South Africa, and Uganda – where, at the health systems level, mental health services were delivered by non-specialist health workers within primary care according to guidelines from the World Health Organization (WHO) Mental Health Gap Action Programme (mhGAP) [
26‐
28]. In Nepal, where roughly 5% of people with depression had access to mental health services prior to the study [
29], researchers also examined the effectiveness of including individual psychotherapy within mhGAP-based mental health services for people with depression and alcohol use disorder [
30]. They found adding individual psychotherapy to a standard package of implemented mhGAP services (i.e. pharmacological and basic psychosocial services) provided by primary care workers led to larger reductions in clinical symptoms and functional impairment for those with depression, though they observed no additional benefit for people with alcohol use disorder [
31].
The present study examined trends in healthcare use and costs among two groups of people with depression: those who received a standard package of care and those who received this package plus individual psychotherapy as part of mhGAP-based treatment for depression. We also studied a third group of people with subclinical depressive symptoms who received usual care (UC), which represents an approximate counterfactual of service use and costs when integrated mental health services are not provided. We examined trends in healthcare use for mental and physical health, separately and combined, to understand what drives healthcare costs. Our methods build on previous research by Chisholm et al. [
32] studying health service costs and their association with functional impairment among PRIME participants in all five country sites. We extend this research by comparing trends over time and across the three study groups for depression in PRIME Nepal and by also examining healthcare use. Oure goal was to provide insight into the individual and health system impacts of including individual psychotherapy within integrated packages of care. These insights can improve our understanding of how integrated mental services affect other healthcare use, ensure those who receive expanded care do not experience undue financial burden, and ultimately inform efforts to integrate and scale up mental services within LMIC.
Discussion
We examined outpatient healthcare use and costs over time among one group of individuals with depression who received a standard package of integrated mental health services, a second group of individuals with depression who received this package plus individual psychotherapy, and a third group of individuals with subclinical depressive symptoms who received care as usual. Healthcare use was low at the start of the study and increased from baseline to three months among all three groups, with increases in use generally corresponding to the level of mental health services provided by the PRIME project to each group (i.e., a high level of PRIME services among TG + P, a moderate level of PRIME services among TG, or no PRIME services among UC). Increases in healthcare use at the three-month follow up were largely driven by mental healthcare, though we also found greater healthcare use for physical health among the subclinical depressive symptoms group at three months. All categories of healthcare use returned to the low baseline levels among all three groups at the 12-month follow-up. Given short-term increases in use were driven by attending PRIME services, low use at long-term follow up likely reflects the discontinuation of mental healthcare use by individuals.
Healthcare use, driven by mental health service use, reflects expected trends and corresponds to the level of care provided under the PRIME group allocation. Depression services, including the 6–8 weekly session psychotherapy provided to the TG + P group, were primarily provided in the first three months of the study, which aligns with guidelines for care in the mhGAP Intervention Guide [
59] and the observed increases in short-term use. Another explanation for observed increases in health visits could be that the additional visits were a byproduct of regular interactions with healthcare workers since healthcare workers encouraged service users to attend regular physical and mental health services during home follow-up as a part of their role. Low mental healthcare use at long-term follow up may be explained by individuals having completed structured interventions in the short-term, such as the Health Activity Program delivered to TG + P participants [
60]; individuals discontinuing care after depressive symptoms improved [
61]; or individuals needing fewer healthcare visits for treatment maintenance as recommended in the mhGAP Intervention Guide [
59].
Healthcare use for physical health remained less than two visits per three months on average across all groups and time points. Short-term increases in use among the individuals with subclinical depression, i.e., the UC group, were driven by outpatient visits for physical health concerns. Physical healthcare visits among this group likely included help seeking for both physical and mental health conditions; visit type was categorized by self-reported presenting concerns and symptoms of mental disorders often present as physical ailments (e.g., headaches, body pains) among people with depression in Nepal [
22,
23]. Conversely, physical health concerns among individuals in the two treatment groups may have been addressed during PRIME mental services, either by treating psychosomatic symptoms or health workers addressing physical health complaints during mental health service delivery.
Individual OOP costs were greatest among TG at 3-month follow up, despite similar OOP costs at baseline across the three groups. Results of post hoc analysis indicated increases in expenditure were due to differences in the location and type of healthcare being received. Those in the TG reported greater healthcare use for physical health as well as more frequently receiving care at traditional healers and specialists, both of which charged higher consultation fees on average than local health centers. Previous research from PRIME Nepal found mhGAP-based care to be less effective in reducing depressive symptoms and functional impairment when psychotherapy was not provided [
31]. Combined with our findings, this evidence may indicate people who received less effective mental health services, i.e., TG, sought supplemental mental and physical healthcare elsewhere. PRIME services also included home-based follow up for both treatment groups, thus reducing OOP expenditure on transportation for mental healthcare and increasing contacts with the health system. We see a similar pattern when expanding our focus to include all health system costs: those receiving TG had greater health system costs at 3-month follow up, driven by higher OOP costs, despite lower overall healthcare use. Limiting health system costs to those for mental healthcare reflected expected trends; health system costs for mental health reflected the level of mental healthcare provided under PRIME Nepal.
To our knowledge, our study the is first to document differences in healthcare use and costs over time among individuals receiving different packages of integrated services for depression within primary care in LMIC. Total healthcare costs were greater among individuals diagnosed with depression compared to individuals without depression in the UC group. This finding aligns with previous cross-sectional research in Nepal [
21] and other PRIME country sites [
32] indicating households with at least one family member with depression have greater healthcare costs than households that do not, as well as with the well-documented economic burden of depression in high-income countries and LMIC [
17‐
20].
Our findings should be interpreted alongside limitations. First, participants were nonrandomly assigned to UC, which is comprised of those who screened positive for depression but were not diagnosed during clinical interview. There were no differences in depressive symptoms at baseline between treatment and UC groups, though functional impairment was lower at baseline among UC individuals [
31]. This difference in functional impairment between those with depression and without depression is expected: those with subclinical symptoms experienced lower impairment. Increases in physical healthcare use at follow up may also reflect a greater physical disease burden among UC participants, though physical healthcare use at baseline was similar among all groups. Though imperfect, the UC group provides the closest available comparator of service users experiencing depressive symptoms within the primary healthcare system in Nepal. As such, we have included UC in the present study as an imperfect comparator and intentionally avoided referring to this group as a control. Second, we examined the costs of
delivering health services according to self-reported resource use and published unit costs for different providers, locations, and medications. Costs associated with training and implementing various mental and physical health services utilized by service users, including those of PRIME Nepal, are beyond the scope of this paper. Future research should investigate whether integrated mental health services provided by PRIME represent cost-effective investments when considering both training and implementation costs. Our findings on the economic impact of integrated services to the service user and health system are limited in scope to service delivery alone. This is true of both PRIME services and other services utilized by study participants, i.e., implementation costs for physical health services are also excluded from our analyses. Lastly, psychotropic medications costs were estimated and assigned to primary care facilities under health systems costs, rather than directly reported by service users or healthcare administrators. Our measure of healthcare use, the CSRI, did not specifically ask respondents to report expenditure on psychotropic medications, though these costs may have been indirectly reported by service users as consultation fees. Since most, if not all, psychotropic medications were provided at no cost to the service users by PRIME health facilities, our approach is likely a close approximation of actual payers and costs.
Conclusion
Two packages of integrated mental health services for depression did not differ in costs to the health system for delivery or service user for utilization despite one of these packages also including individual psychotherapy, which has been found to be the service component that determined effectiveness for treating depression in this context. So, adding psychotherapy to mental health services within primary care significantly increases and determines the effectiveness of depression care, at no additional costs to the health system for service delivery. This is a highly policy-relevant finding, as the combination of knowing what is needed in terms of services to reduce depression and knowing this does not result in undue financial burden to the individual or health system provides for the key arguments for scaling up such services. While our findings provide encouraging results for service users, further research is needed incorporating both implementation and service delivery costs to estimate the full value of integrated mental healthcare to the health system. Future research is also needed on the impact of improved mental health on physical healthcare use; though physical healthcare use was slightly lower among treatment groups compared to usual care over follow up, we were unable to make conclusive statements in this area given the low overall levels of physical healthcare use observed and our sample size. Lastly, we provide evidence individuals often rely on mental and physical health services outside the formal healthcare system, highlighting the continuing role of informal healthcare providers in Nepal. Our findings taken together can be used to inform how, and at what cost, integrated mental health services for depression can be delivered within primary care in Nepal and similar contexts.
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