JMIR Publications

ABSTRACT

Background:

There is evidence from meta-analyses and systematic reviews that digital mental health interventions for depression, anxiety and stress-related disorders tend to be cost-effective. However, no such evidence exists for guided digital mental healthcare in low and middle-income countries facing humanitarian crises, where needs are highest. Step-by-Step (SbS) is a digital mental health intervention for depression, anxiety and stress-related disorders. SbS proved to be effective in Lebanese citizens and war-affected Syrians residing in Lebanon. However, its cost-effectiveness was unknown. Yet, assessing the cost-effectiveness of SbS is crucial because Lebanon’s over-stretched healthcare system must prioritize cost-effective treatment options in the face of continuing humanitarian and economic crises.

Objective:

To assess the cost-effectiveness of SbS in a randomized comparison with enhanced usual care, EUC.

Methods:

The cost-effectiveness analysis was conducted alongside a pragmatic randomized controlled trial in two parallel groups comparing SbS (n=614) with EUC (n=635). The primary outcome was cost (in US$ for the reference year 2019) per treatment Response of depressive symptoms, defined as a more than 50% reduction of depressive symptoms measured by the Patient Health Questionnaire (PHQ). Secondary outcome was cost per Remission of depressive symptoms, defined as a PHQ score below 5 at last follow-up (5 months post baseline). The evaluation was conducted first from the healthcare perspective and again from the societal perspective.

Results:

Taking the healthcare perspective, SbS had an 80% probability to be regarded as cost-effective compared to EUC when there is a willingness to pay $220 per additional treatment Response, or $840 per additional Remission. Taking the wider societal perspective SbS had a more than 75% probability to be cost saving while gaining Response or Remission.

Conclusions:

To our knowledge, this study is the first cost-effectiveness analysis based on a large randomized controlled trial (n=1,249) of a guided digital mental health intervention in a lower middle-income country. Two implications flow from the principal findings. First, as seen from the healthcare perspective our findings suggest that SbS is associated with greater health benefits, albeit for higher costs than EUC. It is up to decision-makers in healthcare to decide if they find the balance between additional health gains and additional healthcare costs acceptable. Second, as seen from the wider societal perspective, there is a substantial likelihood that SbS is not costing more than EUC, but is associated with cost-savings as SBS participants become more productive thus offsetting their healthcare costs. This finding may suggest to policymakers that it is both in the interest of the populations’ health and in the interest of the wider Lebanese economy to implement SbS on a wide scale. In brief, SbS may offer a scalable and potentially cost-saving response to humanitarian emergencies in a lower middle-income country. Clinical Trial: ClinicalTrials.gov NCT03720769; https://clinicaltrials.gov/ct2/show/NCT03720769