Impact of integrated district level mental health care on clinical and functioning outcomes of people with depression and alcohol use disorder in Nepal: A non-randomised controlled study

Background: Integration of mental health services into primary healthcare is proliferating in low-resource countries. We aimed to evaluate the impact of different compositions of primary care mental health services for depression and alcohol use disorder (AUD), when compared to usual primary care services. Methods: We conducted a non-randomized controlled study in rural Nepal. We compared treatment outcomes among patients screening positive and receiving: (a) primary care mental health services without a psychological treatment component (TG); (b) the same services including a psychological treatment (TG + P); and (c) primary care treatment as usual (TAU). Primary outcomes included change in depression and AUD symptoms, as well as disability. Disability was measured using the 12-item WHO Disability Assessment Schedule. Symptom severity was assessed using the 9-item Patient Health Questionnaire for depression, the 10-item Alcohol Use Disorders Identification Test for AUD. We used negative binomial regression models for the analysis. Results: For depression, when combining both treatment groups (TG, n = 77 and TG + P, n = 60) compared to TAU (n = 72), there were no significant improvements. When only comparing the psychological treatment group (TG + P) with TAU, there were significant improvements for symptoms and disability (aβ = - 2.64; 95%CI - 4.55 to - 0.74, p = 0.007; aβ = - 12.20; 95%CI - 19.79 to - 4.62; p = 0.002, respectively). For AUD, when combining both treatment groups (TG, n = 92 and TG + P, n = 80) compared to TAU (n = 57), there were significant improvements in AUD symptoms and disability (aβ = - 15.13; 95%CI - 18.63 to - 11.63, p < 0.001; aβ = - 9.26; 95%CI - 16.41 to - 2.12, p = 0.011; respectively). For AUD, there were no differences between TG and TG + P. Patients' perceptions of health workers' skills in common psychological factors were associated with improvement in depression patient outcomes (β = - 0.36; 95%CI - 0.55 to - 0.18; p < 0.001) but not for AUD patients. Conclusion: Primary care mental health services for depression may only be effective when psychological treatments are included. Health workers' competencies as perceived by patients may be an important indicator for treatment effect. AUD treatment in primary care appears to be beneficial even without additional psychological services.