OBJECTIVES: Integrating mental health services into primary care is a key strategy for reducing the mental health care treatment gap in low- and middle-income countries. We examined trends in health care use and costs among individuals with depression and subclinical depressive symptoms in Chitwan, Nepal to understand the impact of integrated care on individual and health system resources.

METHODS: Individuals diagnosed with depression at ten primary care facilities were randomized to receive psychoeducation and antidepressant medication (TG) or these plus individual psychotherapy (TG+); patients with subclinical depressive symptoms received usual care (UC). We examined changes in outpatient visits, patient out-of-pocket (OOP) health expenditure, and health system costs at 3- and 12-month follow up using Poisson and log-linear models for use and costs, respectively, with an interaction term between time point and study group and TG as reference.

RESULTS: The study included 188 patients (TG=59, TG+=60, UC=69; 86% female, 84% Hindu, 24% formally employed, mean age 41.1). Outpatients visits were similar (-11%, p=0.51) among TG+ and lower (-43%, p=0.01) among UC compared to TG at baseline. Visits increased 83% at 3 months (p<0.001) among TG, with a 41% greater increase (p=0.03) among TG+, before returning to baseline levels among all groups at 12 months. Differences in OOP expenditure were 60% (p=0.04) and 59% (p=0.04) lower at 3 and 12 months, respectively, among TG+; there were no significant differences between UC and TG. Though initially lower among UC (-54%, p=0.005), health system costs did not significantly differ across groups over time, with increases at 3 months among all three before trending downward.

CONCLUSIONS: Delivering psychotherapy within integrated care for depression resulted in greater healthcare use but not necessarily greater costs to the individual or health system; individuals receiving less comprehensive mental health care may supplement with additional more costly health services.