Cost-Effectiveness of Digital Mental Health Versus Usual Care During Humanitarian Crises in Lebanon: Pragmatic Randomized Trial

Background:
Digital mental health interventions for depression, anxiety, and stress-related disorders are generally cost-effective, but evidence is lacking for guided digital mental health care in low and middle-income countries (LMICs) facing humanitarian crises. Step-by-Step (SbS) is effective for Lebanese citizens and war-affected Syrians in Lebanon. Assessing SbS's cost-effectiveness is crucial due to Lebanon's strained health care system.

Objective:
This study aims to assess the cost-effectiveness of SbS compared to enhanced usual care (EUC) through a randomized trial.

Methods:
A cost-effectiveness analysis was conducted with 614 participants receiving SbS and 635 receiving EUC. The primary outcome was cost per treatment response (>50% reduction in depressive symptoms). The secondary outcome was cost per remission (PHQ score <5 at 5 months). The evaluation was conducted from health care and societal perspectives.

Results:
From the health care perspective, SbS had an 80% probability of being cost-effective compared to EUC, with a willingness to pay US $220 per additional treatment response or US $840 per additional remission. From the societal perspective, SbS had a >75% probability of being cost-saving while gaining response or remission.

Conclusions:
This study is the first cost-effectiveness analysis of a guided digital mental health intervention in an LMIC. SbS provides greater health benefits at higher costs from the health care perspective, requiring decision-makers to balance costs and benefits. From the societal perspective, SbS is likely cost-saving due to increased productivity. Implementing SbS on a wide scale could benefit both health and the economy in Lebanon, offering a scalable solution to humanitarian emergencies in LMICs.