ECONOMIC EVALUATION OF INTEGRATED SERVICES FOR DEPRESSION WITHIN PRIMARY CARE IN NEPAL

Most people with depression lack access to adequate mental healthcare in low- and middle-income countries (LMIC). Integrating mental health services into primary care is essential to achieving universal health coverage and reducing the global burden of depression. The World Health Organization Mental Health Gap Action Programme (mhGAP) has been implemented in over 90 countries to guide nonspecialist providers of mental health services within primary care and similar settings. However, evidence is limited on the cost-effectiveness and resource impact of nonspecialist primary care services for people with depression in LMIC. We conducted an economic evaluation of integrated services for people with depression in Chitwan, Nepal using data from the Programme for Improving Mental Health Care (PRIME). Our research focused on two mhGAP-based service packages within primary care: standard care primarily consisted of pharmacotherapy, while care plus combined pharmacological and psychological interventions. In Aim 1, we examined healthcare use and costs among PRIME service users. Despite greater mental healthcare use among care plus service users, we found no significant differences in costs to the health system or individual between service packages. In Aim 2, we examined the cost-effectiveness of care plus compared to standard care using PRIME study data. The incremental cost-effectiveness ratio of care plus was $4,422 per quality adjusted life year gained, approximately $400 above per capita gross domestic product. Implementation costs were high for both packages. In Aim 3, we used economic modeling to extend the time horizon of cost-effectiveness analysis from 12 months to five years since service enrolment and imbed equity analysis. We found care plus cost-effectiveness estimates substantially improved when considering a longer time horizon for treatment effects. We also found health benefits to be equitably distributed across socioeconomic strata, even with individuals of lower socioeconomic status spending less on healthcare. Psychological intervention was a valuable component of integrated services for people with depression in Nepal. Combined pharmacological and psychological services were cost-effective, equitable, and not unduly burdensome to health system or individual resources. Reducing implementation costs and addressing long-term service needs are targets for improving mental healthcare integration within Nepal and similar contexts