Costs and cost-effectiveness of Shamiri, a brief, layperson-delivered intervention for Kenyan adolescents: A randomized controlled trial

Abstract

Abstract Background: Low- and middle-income countries (LMICs) have the highest socio-economic burden of mental health disorders, yet the fewest resources for prevention. Recently, many intervention strategies — including the use of brief, scalable interventions— have emerged as ways of reducing the mental health treatment gap in LMICs. But how do decision makers prioritize and optimize the allocation of limited resources? One approach is through the evaluation of delivery costs alongside intervention effectiveness of various types of interventions. Here, we evaluate the cost-effectiveness of Shamiri, a group– and school–based intervention for adolescent depression and anxiety that is delivered by lay-provider and that teaches growth mindset, gratitude, and value affirmation. Methods: We estimated the cost-effectiveness of Shamiri using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines for economic evaluations. Changes in depression and anxiety were estimated at treatment termination and 7-month follow-up using a standard definition and reliable and clinically significant change definition of treatment benefit. Cost-effectiveness metrics included effectiveness-cost ratios and cost per number needed to treat. Results: Base case cost assumptions estimated that delivering Shamiri cost $15.17 (in 2021 U.S dollars) per student. A sensitivity analysis, which varied cost and clinical change definitions, estimated it cost between $48.28 and $172.72 to help 1 student in Shamiri, relative to the control, achieve reliable and clinically significant change in depression and anxiety by 7-month follow-up. Conclusions: Shamiri appears to be a low-cost intervention that can produce clinically meaningful reductions in depression and anxiety. Lay providers can deliver effective treatment for a fraction of the time that is required to become a licensed mental health provider (10 days vs. multiple years), which is a strength from an economic perspective. Additionally, Shamiri produced reliable and clinically significant reductions in depression and anxiety after only 4 weekly sessions instead of the traditional 12-16 weekly sessions necessary for gold-standard cognitive behavioral therapy. The cost per “treated” student is acceptable relative to other school-based adolescent mental health interventions that have ranged from $52 to $56,500 per student with a successful outcome. Trial registration: This study was registered prior to participant enrollment in the Pan-African Clinical Trials Registry (PACTR201906525818462), registered 20 Jun 2019, https://pactr.samrc.ac.za/Search.aspx.