> For the complete documentation index, see [llms.txt](https://research.ambitiousimpact.com/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://research.ambitiousimpact.com/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs.md). # Treating depression with guided digital self-help programs ## Summary ### Description This report assesses a potential charity delivering a digital guided self-help program for adults with depression in low- and middle-income countries (LMICs). The model builds on the World Health Organization’s (WHO) Step-by-Step program and the approach used by Kaya Guides, an AIM-incubated mental health nonprofit. Depression is one of the leading causes of disability worldwide, affecting more than 300 million people. The burden falls disproportionately on LMICs, where access to care is extremely limited: the WHO estimates that around 75% of people who need mental health treatment receive no care at all, largely due to severe shortages of trained providers. As a result, most people with depression in these settings are left without effective support. ### Expected impact [**Cost-effectiveness**](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/6-cost-effectiveness-analysis.md)**:** The intervention meets AIM’s cost-effectiveness bar across all modeling approaches and countries assessed. Average cost-effectiveness is estimated at $97 per DALY averted or $25 per WELLBY. **Scale:** Our modeling assumes the charity reaches 100,000 people at scale, resulting in approximately 25,000 program completers and an estimated 14,000 DALYs averted annually, including household spillover effects. ### Potential for success [**Evidence base**](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/3-quality-of-evidence.md)**:**\ There is strong evidence supporting guided self-help for depression: * Kaya Guides demonstrates real-world feasibility of implementing WHO Step-by-Step in an LMIC context. * Meta-analytic evidence indicates guided self-help achieves effects comparable to face-to-face psychotherapy, despite requiring far fewer resources. * Five randomized controlled trials (RCTs) (total n = 2,210) of Step-by-Step in LMICs found statistically significant improvements relative to enhanced usual care. As with much of the digital mental health literature, these studies face limitations related to attrition and reliance on self-reported outcomes. **Durability of effects:** Evidence on long-term outcomes is limited. The Step-by-Step RCTs include only three-month follow-up data, although one study found effects increased over this period. Evidence from other guided self-help interventions suggests effects may persist for up to 12 months; beyond that, outcomes are either unstudied or no longer statistically significant. Longer-term estimates (e.g. 3–5 years) are based on evidence from psychotherapy more broadly, and their applicability to guided digital self-help is uncertain. [**Theory of change**](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/2-theory-of-change.md)**:** The proposed charity would deliver a five-session behavioral activation program via WhatsApp. Participants would complete short, structured modules independently and receive brief weekly check-ins by phone from trained lay counselors over the five-week program. A small supervisory team would oversee counselors and review flagged cases. ### Neglectedness [**Existing activity**](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/5-existing-activity-funding-and-geographic-assessment.md)**:** Work on this intervention remains highly neglected. Kaya Guides is the first non-profit to implement WHO’s Step-by-Step program. [**Geographic fit**](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/5-existing-activity-funding-and-geographic-assessment.md)**:** Based on disease burden, connectivity, cost considerations, and household size (as a proxy for potential spillover effects), the most promising countries are Pakistan, China, Nigeria, Bangladesh, Indonesia, Egypt, Brazil, Tajikistan, Ethiopia, and Malaysia. All meet our cost-effectiveness bar. ### Relevance **Strategic value to AIM:** This intervention is not expected to have high strategic value for AIM, as we have already supported the launch of a digital guided self-help provider (Kaya Guides) and several other charities focused on mental health (Happier Lives Institute, Canopie, and Vida Plena). **Fit for the CEIP:** We expect this intervention to be attractive to potential co-founders. Useful backgrounds for co-founders or early hires would include technical skills for product development, training in psychology or mental health to support program design, outreach or marketing experience, and local knowledge to help adapt content appropriately to new countries, contexts, and languages. ### Other [**Expert views**](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/4-expert-views.md)**:** Kenneth Carswell (WHO) provided implementation guidance and directed us to WHO resources on Step-by-Step. Huw Evans (Kaya Guides) shared practical implementation experience that informed our understanding, approach, and modeling throughout the report. [**Implementation factors**](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/7-implementation-considerations.md)**:** The main implementation challenge is scaling. Kaya Guides serves as the primary proof of concept for this intervention, but remains relatively early-stage, having treated approximately 3,600 people to date. While the organization aims to reach 100,000 people by Year 5, evidence from other implementations of WHO’s Step-by-Step program is similarly limited in scale. One of the largest rollouts to date is Thailand's national implementation in partnership with WHO, which launched in May 2025 and is also still in its early stages. A related concern is talent. While we expect it to be feasible to identify strong co-founders for this intervention, scaling delivery requires recruiting and managing a large number of lay counselors and supervisors. Kaya Guides is currently attempting to double counselor headcount roughly every six months (around fourfold annual growth) to meet its target of 100,000 participants, but progress is constrained by HR and management capacity. ## Crucial Considerations ### What scale could a new organization reach? We currently model a reach of 100,000 people at scale (equivalent to approximately 25,000 program completers) based on Kaya Guides’ ambitions to reach this level by Year 5. However, there is significant uncertainty around how realistic this target is. Kaya Guides was incubated in 2022 and launched its WhatsApp-based program in August 2023. Since then, it has grown from 700 to approximately 3,600 participants, though the feasibility of sustaining this pace remains uncertain due to HR and management constraints. ### How durable are the effects of this intervention? Our model applies a one-year duration of effects, though there is considerable uncertainty around how durable the effects are in practice. The evidence base for long-term impacts is limited. * The five RCTs on the WHO Step-by-Step program include only a three-month follow-up. One study found that effects strengthened over this period, with depression effect size increasing from SMD=0.48 post-treatment to SMD=0.61 at three months. * Evidence from other guided self-help interventions suggests effects may persist for up to 12 months, but outcomes beyond this point are either unstudied or no longer statistically significant. One meta-analysis found effects declining to MD=-0.5 (barely significant) at 12 months, while another reported a 33% reduction in effect size between 6–9 months and 10–12 months (g=0.74 to g=0.49). * HLI's meta-analysis of psychotherapy more broadly estimates effects lasting 3.48 years, or 5.36 when including some unusually long-term follow-up periods ([McGuire et al., 2024](https://www.happierlivesinstitute.org/wp-content/uploads/2025/11/The-wellbeing-cost-effectiveness-of-StrongMinds-and-Friendship-Bench-Combining-a-systematic-review-and-meta-analysis-with-charity-related-data-Nov-2024-Update.pdf)). * HLI uses 3.48 years in its CEAs of Friendship Bench and StrongMinds. Table 1 shows how cost-effectiveness estimates vary under different assumptions about the duration of effects and across the two modeling methods used in [our CEA model](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/6-cost-effectiveness-analysis.md). **Table 1: Sensitivity analysis on duration of effects (average cost-effectiveness across modeled countries, $/DALY)** | Duration of effects | Method 1 | Method 2 | Average across methods | | ----------------------------------------------------------------------------------------------------------------------------------------------------------------- | -------- | -------- | ---------------------- | | **1 year (current model)** | **120** | **82** | **97** | | **3 months (WHO Step-by-Step RCT follow-up)** | 481 | 326 | 389 | | **6.5 months (minimum duration to meet our cost-effectiveness bar)** | 222 | 151 | 180 | | **8 months (**[**Mamukashvili-**](https://pmc.ncbi.nlm.nih.gov/articles/PMC10481211/) [**Delau’s 2023**](https://pmc.ncbi.nlm.nih.gov/articles/PMC10481211/)**)** | 180 | 122 | 145 | | **1 year with decay (100% for first 6 months and 50% for second 6 months)** | 160 | 109 | 130 | | **1 year with** [**decay**](#user-content-fn-1)[^1] **(**[**Cuijpers, 2023**](https://pmc.ncbi.nlm.nih.gov/articles/PMC9840507/)**)** | 131 | 89 | 106 | | **3.48 years (used by Kaya Guides)** | 35 | 23 | 28 | Based on Table 1, effects would need to last at least 6.5 months for this intervention to meet our cost-effectiveness bar of $220 per DALY across all three methods. Current evidence from WHO Step-by-Step trials only track outcomes over a three-month period, leaving a gap between observed effects and the duration required for strong cost-effectiveness. This reflects a lack of long-term evidence rather than evidence that effects do not persist. ### Recruitment at scale * **Recruiting lay counselors**: Kaya Guides reports that it has been able to successfully recruit lay professionals through local job advertisements, with many guides drawn from psychology students or women with master’s degrees. However, scaling this model remains a challenge. Kaya Guides is currently attempting to double counselor headcount roughly every six months (around fourfold annual growth) in order to reach its goal of 100,000 participants by Year 5, but progress is constrained by HR and management capacity. * **Recruiting participants**: Kaya Guides currently recruits participants through targeted Meta advertising, largely via Instagram. In its pilot, the organization was highly successful at recruiting its target population: 97% of participants who completed the baseline depression questionnaire met criteria for depression, and 82% scored in the moderate-to-severe range ([Abbott, 2024](https://forum.effectivealtruism.org/posts/6NaRJpSn2zfRSnGYN/kaya-guides-pilot-results)). This suggests that targeted digital ads can be an effective recruitment channel for this population. While digital delivery may make recruitment easier than in-person group therapy, scaling remains nontrivial. According to Huw Evans, Kaya Guides is currently bottlenecked by staffing and funding despite demand for its program. Vida Plena, which provides community-led depression treatment in Latin America, has also faced recruitment challenges. At the same time, experience from other large LMIC mental-health programs shows that high-volume recruitment is possible: StrongMinds reports reaching 240,000 people in Uganda and Zambia in 2023 ([StrongMinds, 2023](https://strongminds.org/wp-content/uploads/2024/05/2023-Q4-report-8.5x11-03-28-24-FINAL.pdf)), and Friendship Bench reports serving more than 800,000 people across its programs ([Friendship Bench, n.d.](https://www.friendshipbench.org/?gad_source=1\&gad_campaignid=22066093623\&gbraid=0AAAAA-piCpb0iLSOUHhzHTdPzLPtM0Be7\&gclid=Cj0KCQiAq7HIBhDoARIsAOATDxCuv-HIbS_sTs2x8Rm1fiBUEPUcq7xAqkCni94C04eccezRsokiFAQaAoyHEALw_wcB)). Our CEA assumes that a new charity could reach 100,000 people by Year 5, in line with Kaya Guides’ scaling ambitions. However, this projection is uncertain. We assume that approximately 45% of recruited participants do not complete the first session[^2], and only around 25% (25,000 people) complete all five sessions. To date, Kaya Guides has reached approximately 3,600 people since launching in August 2023. While this demonstrates early traction, it remains uncertain whether the organization, or a new entrant, can scale to this level within five years. Recruitment information from WHO Step-by-Step RCTs: * [Cuijpers et al., 2022a](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004025): “Recruitment of participants took place through advertising for the research project on several social media platforms, by posting and boosting posts on the official social media pages of the National Mental Health Programme on Facebook and Instagram. Additionally, outreach methods took place with the network of NGOs and UN agencies taking part in a mental health and psychosocial support taskforce whereby meetings were held in different regions with the Syrian community to introduce the project, followed by WhatsApp broadcasts that were sent by the organizations to their Syrian beneficiaries… As remuneration for completing all the questionnaires, users received $20 phone credit.” * [Cuijpers et al., 2022b](https://pmc.ncbi.nlm.nih.gov/articles/PMC9811068/): As above - Participants were recruited through online advertisements and social media and received remuneration of $20 phone credit. * [Heim et al., 2021](https://pmc.ncbi.nlm.nih.gov/articles/PMC7967003/): Participants were recruited through social media (Facebook and WhatsApp), using advertisements developed by a communications and advertising company based on focus group testing. “A partnership was established with UNHCR to support dissemination of the posts to the Syrian community via their messaging strategy over WhatsApp and through their outreach volunteers. Organizations in the Mental Health and Psychosocial Support (MHPSS) taskforce were also approached to help disseminate the project among their beneficiaries, and a group of social workers from the International Medical Corps (IMC) have been trained to introduce the project in their outreach activities.” * Participants do not appear to have received financial compensation for participation in this study. * [Li et al., 2024](https://pmc.ncbi.nlm.nih.gov/articles/PMC10879210/): “Participants were recruited via (1) university daily news; (2) posters and leaflets on campus; (3) presentations by research staff; and, (4) referrals from the university counseling center \[…] Participants received compensation for posttreatment and follow-up assessments ($6 and $12 US dollars, respectively).” * [Burchert et al. 2024](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004460): “Participant recruitment was carried out in collaboration with Caritas Egypt, an NGO with a long track record in providing health services to refugees in the Alexandria metropolitan area. The NGO team reached out to potential participants, provided information on the study, and supported study processes onsite… Participants received a compensation of 150 Egyptian pounds (EGP; equivalent to 9 USD) for the post and the follow-up assessments, respectively.” * **Recruiting supervisors**: At scale, we estimate a need for 17 supervisors. Based on Kaya Guides’ experience, we expect it would be feasible to recruit supervisors through local job advertisements. However, Kaya Guides has not reached a scale that requires more than one supervisor, so there is some uncertainty around how this would translate at a larger scale. **Based on this, our primary concern is HR and management capacity at scale** rather than recruitment of lay professionals, participants, or supervisors. Our CEA assumes 15 HR/management staff (in addition to co-founders) at scale. This concern is informed largely by Huw’s comments, though we do not believe this level of senior staffing is implausible. For context, [Fortify Health](https://www.fortifyhealth.global/meet-the-team.html) appears to have 10 people in leadership roles and a further 33 staff with senior or manager titles, while [Suvita](https://www.suvita.org/our-team) appears to have 17 non-ground staff and an additional 12 staff in senior roles (both figures include co-founders). [^1]: [Cuijpers, 2023](https://pmc.ncbi.nlm.nih.gov/articles/PMC9840507/) found a 33% reduction in effect size from 6–9 months to 10–12 months (g=0.74 to g=0.49). [^2]: We think in reality more participants might complete their first sessions, as Kaya Guides data shows they have higher rates of early completion (see [Section 6.2.2](/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs/6-cost-effectiveness-analysis.md)) --- # Agent Instructions This documentation is published with GitBook. GitBook is the documentation platform designed so that both humans and AI agents can read, navigate, and reason over technical content effectively. Learn more at gitbook.com. ## Querying This Documentation If you need additional information that is not directly available in this page, you can query the documentation by asking a question. Perform an HTTP GET request on the following URL with the `ask` and `goal` query parameters: ``` GET https://research.ambitiousimpact.com/treating-depression-with-guided-digital-self-help-programs/treating-depression-with-guided-digital-self-help-programs.md?ask=&goal= ``` `ask` is the immediate question: it should be specific, self-contained, and written in natural language. `goal` is what the user is ultimately trying to achieve, the reason they need the answer. Sharing it helps GitBook give you a better, more relevant answer. A goal is most helpful when it describes the outcome the user wants rather than restating the question. For example, with `ask=how do I create an API token`, a goal like `automate deployments from our CI pipeline` lets GitBook tailor the answer to that use case. The response will contain a direct answer to the question and relevant excerpts and sources from the documentation. Use this mechanism when the answer is not explicitly present in the current page, you need clarification or additional context, or you want to retrieve related documentation sections.