Impact of a district mental health care plan on suicidality among patients with depression and alcohol use disorder in Nepal

• Published in: PloS one 2020-04, Vol.15 (4), p.e0231158
• Main Authors: Aldridge, Luke R, Garman, Emily C, Luitel, Nagendra P, Jordans, Mark J D
• Format: Article
• Language: English
• Subjects: Adult; Alcohol use; Alcoholism - diagnosis; Alcoholism - psychology; Alcoholism - therapy; Analysis; Biology and Life Sciences; Community Mental Health Services - organization & administration; Community Participation; Decision making; Depression (Mood disorder); Depression - diagnosis; Depression - psychology; Depression - therapy; Drinking (Alcoholic beverages); Female; Health aspects; Health care; Health care reform; Health insurance; Health Plan Implementation; Health services; Humans; Intervention; Male; Medical personnel; Medicine and Health Sciences; Mental depression; Mental disorders; Mental health; Mental health services; Middle Aged; Mortality; Nepal; Nepal - epidemiology; Patients; People and Places; Physical Sciences; Primary Health Care - organization & administration; Program Evaluation; Psychological aspects; Risk Factors; Setting (Literature); Social Sciences; Suicidal behavior; Suicide; Suicide - statistics & numerical data; Suicide Prevention; Suicides & suicide attempts; Time; Workers
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0231158

Large scale efforts to expand access to mental healthcare in low- and middle-income countries have focused on integrating mental health services into primary care settings using a task sharing approach delivered by non-specialist health workers. Given the link between mental disorders and risk of suicide mortality, treating common mental disorders using this approach may be a key strategy to reducing suicidality. The Programme for Improving Mental Health Care (PRIME) evaluated mental health services for common mental disorders delivered by non-specialist health workers at ten primary care facilities in Chitwan, Nepal from 2014 to 2016. In this paper, we present the indirect impact of treatment on suicidality, as measured by suicidal ideation, among treatment and comparison cohorts for depression and AUD using multilevel logistic regression. Patients in the treatment cohort for depression had a greater reduction in ideation relative to those in the comparison cohort from baseline to three months (OR = 0.16, 95% CI: 0.05-0.59; p = 0.01) and twelve months (OR = 0.31, 95% CI: 0.08-1.12; p = 0.07), with a significant effect of treatment over time (p = 0.02). Among the AUD cohorts, there were no significant differences between treatment and comparison cohorts in the change in ideation from baseline to three months (OR = 0.64, 95% CI: 0.07-6.26; p = 0.70) or twelve months (OR = 0.46, 95% CI: 0.06-3.27; p = 0.44), and there was no effect of treatment over time (p = 0.72). The results provide evidence integrated mental health services for depression benefit patients by accelerating the rate at which suicidal ideation naturally abates over time. Integrated services do not appear to impact ideation among people with AUD, though baseline levels of ideation were much lower than for those with depression and may have led to floor effects. The findings highlight the importance of addressing suicidality as a specific target-rather than an indirect effect-of treatment in community-based mental healthcare programs.