Mechanisms and Cost-Effectiveness of Mobile Phone-Based Tele-Support Psychotherapy Delivered by Lay Counselors for Depression Among Youth in Uganda: Secondary Analyses of a Pilot Randomized Controlled Trial

Background: Depression is a critical public health issue among youth in Uganda, with limited access to mental health services. This pilot randomized controlled trial (RCT) evaluated the mechanisms and cost-effectiveness of mobile phone-based Tele-Support Psychotherapy (TSP) delivered by lay counselors for youth with depression in Kampala. Methods: We randomized 300 youth aged 15–30 with mild to moderate depression to TSP combined with Standard Mental Health Services (SMHS) or SMHS alone. Assessments at baseline, 6, and 12 months measured depression (Mini International Neuropsychiatric Interview), stigma, and income generation. Generalized structural equation modeling (GSEM) explored mediation pathways, and a provider-perspective cost-effectiveness analysis calculated the incremental cost-effectiveness ratio (ICER) using disability-adjusted life years (DALYs). Results: TSP significantly reduced depression through stigma reduction and increased income generation (total effect β = -3.736, p<0.001, 95% CI [-4.273, -3.198]). The ICER was US$2,293 per DALY averted, cost-effective compared to Uganda’s GDP per capita (US$1,002). Conclusions: TSP is an effective and cost-effective intervention for youth depression in low-resource settings, with potential for integration into national mental health strategies. Trial Registration: PACTR202201684613316.