Mental Health Shallow Review

post by Elizabeth · 2017-11-20T18:34:24.355Z · score: 34 (36 votes) · EA · GW · Legacy · 30 comments

Contents

  Unexplored Interventions
None
30 comments



What is the problem?

Mental illness is a big umbrella covering many problems, some of which don’t have very much in common.  Broadly defined, a mental illness is a condition affecting a person’s thinking, emotions, or mood, which lacks a physical or environmental explanation. For example, both thyroid deficiency and the death of a child can cause low mood, but the former is not considered depression at all, and the latter is not considered depression unless it persists past the normal grieving period (although the definition of “normal” here is fraught). Meanwhile substance abuse does not strictly follow this definition, since it often has a physical component, but is classified as a mental illness medically and so is included in this review.

 

Mental illness is one of few issues in the first world that may be able to compete with issues in the third world- both because it is defined as misery independent of material circumstances, and because mental illness appears to increase with economic growth (although that is confounded by many things, e.g. depression is easier to identify when someone is in good material circumstances). It may also have a higher economic impact, because it is more likely to hit people in prime working age than most illnesses.

 

This review will cover the top three mental health issues by DALY burden (as estimated by the Institute for Health Metrics): depression, anxiety, and substance use disorder.



Cost: Direct DALY Losses (global)

The Institute for Health Metric’s Global Burden of Disease study estimates the worldwide DALY burden of mental health issues at 170 million DALYs, representing 7% of the overall DALY burden. Within mental health, the top three issues are depression (50 million DALYs), anxiety (25 million), and alcohol and drug abuse (24 million). The next most serious issue is schizophrenia (15 million). Schizophrenia is significantly less understood and harder to treat than the first three, so I will not investigate it here. Given the difficulties estimating DALYs these numbers should be taken as very rough estimates.

 

The WHO estimates global prevalence of depression at 300 million people, leading to ~800,000 suicides/year.

 

Cost: Productivity Loss (first world)

Depression can cause enormous decreases in performance. Beck, et. al. (2011) estimate that a 1 point increase on the PHQ-9 depression scale (out of 27) causes a 1.65% decrease in productivity. In 2000, the University of Michigan estimated depression causes $83 billion in economic loss per year in the US, of which $52 billion was lost work productivity.

 

Depression among otherwise high potential populations is very high, and this may reduce the human capital available to address the world’s problems. For example, 56% of people taking the LessWrong 2016 survey from the Effective Altruism Hub (indicating an EA population) reported having depression. Many studies find similar rates of depression among graduate students and even gifted secondary school students.

 

A short search revealed no reputable numbers for productivity loss due to anxiety. One option is to assume it scales with DALY loss, in which case anxiety causes ~$40 billion in economic loss each year.

 

Rice (1995) estimates that substance abuse led to $290 billion in economic losses in the US in 1995. This is more likely to be an overestimate than other categories of mental illness, given the politicization of substance abuse.

 

Cost: Productivity Losses (global)

The World Economic Foundation estimates global economic loss due to mental illness at $2.5 trillion. Because economic loss includes wages, this is likely to be concentrated in high-income countries. However given the diminishing marginal returns to money, it is possible the resultant suffering is still higher in low-income countries.

Possible interventions

Lithium in the Water Supply

Lithium is commonly used in large doses to treat bipolar disorder. Correlational studies suggest that in very small doses it may be a general mood enhancer and reduce incidence of suicide. OpenPhil’s back of the envelope calculation estimates that adding lithium to the water supply could, best case, save thousands of lives per year in the US by reducing suicide (no cost estimate given). Lithium in the water supply is an attractive intervention because it is cheap and highly scalable, but appears to be low impact.

 

Increased Access to Medication and Therapy (first world)

Common wisdom and some research suggest that neither medication nor therapy alone significantly outperform placebo versions of the same, although when combined they slightly do. These studies are hard to interpret; is there no effect, or is there a large effect among only a small percentage of subjects? Other studies show that medication and therapy are both cost effective, for example Sava, et al. (2009) finds a $/QALY of $1,638, $1,734, and $2,287 for cognitive therapy, rational emotive behavioral therapy, and fluoxetine (Prozac) respectively.

Note that these are QALYs, and most numbers in this report are DALYs. QALYs are likely cheaper than DALYs, especially for mental health.

Suicide and Crisis Hotlines (first world)

I previously estimated the cost-effectiveness of volunteer-staffed suicide hotlines as quite high, costing under $5,000/life saved. This is probably a gross overestimate of effectiveness caused by my bias as a volunteer at a hotline. I also failed to consider the emotional damage done by bad hotline workers, which may be quite high. In their favor, hotlines are cheaper and more scalable than trained professionals. Improved training and monitoring for hotline workers may be a more effective target than simply scaling up existing programs.

 

Self-administered Therapy (first world)

Internet-based cognitive behavioral therapy (CBT) shows strong improvements for anxiety and moderate improvement for depression, but only in conjunction with a therapist (Spek, Cuijpers, Nyklicek, & Riper, 2007; Andersson & Cuijpers, 2009). Internet based CBT is cheaper and more scalable than in-person therapy, and CBT in general is more evidence backed and shows more improvement in a shorter duration than most talk therapy. Other studies go further, stating that self-administered therapy is just as effective as therapist-administered therapy (meta-analysis).

 

Self-administered therapy is cheap and highly scalable; due to this it is already widely available, in the form of various apps, websites, and books. Any intervention using self-administered therapy would either need to make it more accessible, or find an unusually effective but unknown therapy.

 

Mindfulness Based Stress Reduction (first world)

MBSR is a workshop and practice based on Buddhist meditation. It has shown consistent moderate results in improving mental health, and some suggestive results for physical health (Goldin & Gross, 2010). Because it is taught in a class format it is more scalable than individual therapy, and could perhaps be made more so.

 

Using a model described here, I estimate the $/DALY of MBSR at $43-$5200.

 

Media Campaigns (first world)

Very scant research (Kelly, Jorm, and Wright, 2007) suggests that media campaigns to improve youth mental health improve tested knowledge of mental illness but have at best a very small positive effect on help-seeking behavior.

Media Campaigns (third world)

Development Media International is an NGO that produces TV, radio, and mobile phone campaigns to encourage healthy behaviors in several African countries. Philosopher Michael Plant has suggested that similar campaigns for mental/emotional health behaviors could increase adoption of those behaviors, and thus increase happiness and mental health (personal communication). DMI’s current efficacy is ambiguous- study midline results were positive but endline results showed no change, but DMI believes the endline data is flawed.  If emotional behaviors are harder to spread than physical health behavior, this suggests that media campaigns are unlikely to be effective. If emotional behavior is easier to spread, the data is uninformative.

 

A second option is that instead of advocating behaviors, a media campaign could aim to destigmatize mental illness and seeking treatment for mental illness. Mental health literacy is lower in developing countries, so campaigns there may be more fruitful than in the developed world. On the other hand, given how culturally fraught mental illness is, this seems unlikely to be best done by a Western NGO.

 

Gratitude Journals for Schoolchildren (first world)

Many popular articles have pitched gratitude journals as increasing happiness. However a survey of the first ten pages on a Google scholar search for “gratitude journal” (Froh, Sefick, & Emmons, 2007; Rash, Mastuba & Prkachin 2011, Froh et al. 2008) shows only very mild gains, in studies whose designs are very favorable to finding an effect.

 

Interpersonal Group Therapy (third world)

Bolton, et al. (2003) studied a 16 week group-based interpersonal psychotherapy. This consisted of 16 weekly meetings of 8-12 individuals in which a facilitator led individual participants through a review of their mood over the past week and the group made suggestions for improvements. Results measured immediately after treatment were quite promising: on a depression test with an unknown scale, subjects experienced a mean drop of 17.5 points, compared to a drop of 3.6 for controls. On a functional impairment test with an unknown scale, subjects averaged a 8.1 point loss (where a loss in points indicates a gain in function), compared to 3.8 for controls. These improvements were still present at the six month follow up. Note that the control group was not prevented from seeking other treatment, so this gain is relative to culturally standard treatment.

 

Strong Minds is a young NGO that offers 12 week group treatments to women in Uganda based on the intervention described in the above studies. Their first study showed similar gains in both depression scores and outcomes like deployment. A follow up study two years later showed that the improvement in depression persisted, however the control group was too small to be useful, and a crash in the Ugandan economy swamped any economic changes.

 

Based on the first study, the Oxford Prioritisation Project estimated that Strong Minds costs $650 per DALY averted.

Drug Liberalization (first world)

There are many scheduled drugs in the US that could have medical benefits, and lobbying for their liberalization would be an effective action. Three examples are marijuana, MDMA, and psychedelics.

 

Some drug use is motivated not by pure addiction, but by a problem the user is attempting to self-medicate. In particular, opioid overuse can be caused by chronic pain. Treating the problem with a safer or more efficacious substance can improve quality of life while decreasing risk. One example of this is medical marijuana, which when legalized lowered death from opioid overdoses by 33%.

 

The Multidisciplinary Association for Psychedelic Studies is investigating MDMA for treatment of PTSD and multiple psychedelics for treatment of depression and anxiety, with promising initial results. They are the only non-profit organization that has ever attempted to take a substance through the FDA approval process, and are strongly funding constrained. Identifying other highly effective substances that are illegal or simply off-patent and lobbying for their legality could unlock a great deal of value.

 

For more on liberalization, see Michael Plant’s series of posts on the Effective Altruism Forum, and [redacted at author's request] on psychedelic legalization on the same forum, in which he estimates the combined return to lobbying to liberalize and subsequent therapeutic use of psychedelics at $52,000-$442,000/DALY.

 

Who else is working on this?

Mental health in the first world is a crowded field with no non-governmental comprehensive organizations. The following are presented to give an idea of the breadth of existing organizations, not a full understanding. Organizations on this list were either discovered in the course of researching interventions, or came up in google searches for organizations targeting mental health.

 

First World (latest available budget noted when possible):

 

Third World:

 

Questions for further investigation

Many mental health issues in the developing world stem from material deprivation and hardship (lack of food, death of a child). Treating the mental health effects when prevention is available for the actual hardship seems twisted.

 

Effectiveness estimates of other charities (e.g. AMF) generally include only the physical effects of an intervention, even though it presumably has mental health benefits. Leaving out the mental health benefits puts the physical intervention at a disadvantage. I created a simple model on Guesstimate to estimate the mental health impact of bednets for malaria and found it insignificant relative to the physical health benefits.

 

Depression can make a materially rich person feel as miserable as a person facing intense material deprivation. How important is the feeling of misery, vs the actual deprivation?

Unexplored Interventions

I could not possibly explore all available interventions, this is a list of interventions that could benefit from further exploration

Drug Education (first world)

Loudly telling children to not do drugs is the most common form of drug education in public schools. Research reveals that this actually increases drug consumption.

 

Public Health Interventions (first world)

There is good reason to believe that changes in the modern world are causing increases in mental illness. For example, living in a city increases the risk of schizophrenia, and loneliness is an enormous contributor to depression. “Redesign society to make everything better” is beyond the scope of this document, but would probably have many positive spillover effects.

 

Narrative Exposure Therapy (third world)

A combination of CBT and testimony therapy. One study showed it made great strides against PTSD in a refugee camp, relative to no treatment or supportive counseling.

 

Lower Barriers to Entry to Providing Therapy (first world)

Much of the cost of therapy is driven by the cost of becoming certified to provide it. A small study from 1979 suggests that much of the benefit of therapy can be duplicated by a smart, empathetic person, which suggests that removing barriers to entry could decrease costs with no effect on quality. However many therapy-like things, including new age treatments and life coaching, are already available with no licensing, meaning there is probably little room for improvement.

 

Increased access to antidepressants (third world)

Researchers described this as impractical, given the difficulty in providing consistent access to medication in developing countries, especially in rural areas. Consistent access is especially important for psychoactive medications, many of which are dangerous to discontinue abruptly, and may become less effective if frequently stopped and restarted. These same researchers also cited the cost as prohibitive. However the same things were as much if not more true of HIV medication 20 years ago, and NGOs made great strides in increasing access and bringing down the cost. At a minimum, it seems plausible to provide access to antidepressants to individuals who already have prolonged interactions with the health care system.

 

Methadone (global)

Methadone is given to opiate addicts. It is intended to reduce addiction to opiates, however according to Elizabeth Pisani, a global health worker, methadone does not reduce addiction, but does lead/allow addicts to make smarter choices when heroin is scarce. Additionally, methadone is considered by some doctors to be more dangerous than Oxycontin or heroin.

 

Conclusion

My original summary was “Mental health is a highly neglected problem”. This is not quite true: there are many organizations dedicated to the problem. However it is still substantially undertreated, with no signs of a tractable solution (with the possible exception of mindfulness based stress reduction for moderate cases, and Strong Mind's group therapy). The most effective use of funds might be to seed research for new interventions or how to create scalable interventions out of currently unscalable ones.

 

But if pressed, I would give the following recommendations, in ascending order of certainty

 

  1. Duplicate StrongMind's model in other countries. A representative I talked to said they would be interested in helping clone charities get off the ground.
  2. Research how to optimize and spread Mindfulness Based Stress Reduction.
  3. Research how to improve the state of measurement of mental illness, and illness in general, so reports like this can be less vague.

Documents of Interest

Is effective altruism overlooking human happiness and mental health? I argue it is.” Michael Plant, 2016

Mental Health.” James Snowden and Konstantin Sietzy, 2016.

Treating depression in the developing world.” Vikram Patel, Ricardo Araya, and Paul Bolton, 2004.

 PAF: Mental Health in Sub-Saharan Africa.” Ashley Demming, Eric Gastfriend, Lori Holleran, and Danielle Wang.

 

[Edited after publication to deal with formatting discrepancies arising from copypasting a Google docs]

 

[Edited on 8/30/18 to remove a link at author's request]

 

Thanks to Peter Hurford for funding this research.

30 comments

Comments sorted by top scores.

comment by Benjamin_Todd · 2017-11-22T06:06:57.432Z · score: 7 (7 votes) · EA(p) · GW(p)

Great post, like all the data, and would be keen to see more work like this. I've added a link to it here: https://80000hours.org/articles/cause-selection/

Some more questions I'd be interested in:

1) I'd be interested to see more on how you think it compares to other EA causes all considered, especially the most similar one, global health. I'd start with taking a short-term DALYs and economic perspective, but would also be interested in what a long-term perspective might say about the comparison (I've almost seen nothing about this)

2) I'd be interested to see firmer recommendations for people who have already decided they want to focus on mental health - what are your thoughts on the most promising interventions and career paths?

comment by Elizabeth · 2017-11-22T16:17:56.389Z · score: 3 (3 votes) · EA(p) · GW(p)

Thanks Ben, this is very helpful as I revise the report.

For (1): my research showed that as bad as the existing options for measuring utils are, they're worse for mental health. I'd originally published this on my own blog to avoid spamming EA Forums, but this is the second time I'm linking to it in the comments so I've posted it hear as well: http://effective-altruism.com/ea/1he/measuring_the_impact_of_mental_illness_on_quality/. You might also be interested in a DALY/$ estimate I made for Mindfulness Based Stress Reduction: https://acesounderglass.com/2017/11/20/cost-effectiveness-of-mindfulness-based-stress-reduction/ .

For (2): I'll update the doc to reflect this, but in order of increasing abstraction:

'1. Copy StrongMind's model to other poor countries. A SM representative I talked to said they would be happy to help get other charities off the ground.

'2. Research how to optimize mindfulness, make it palatable to the general public, and expand the circle of people it helps/has been demonstrated to help. I met an organization working on this for business at a conference and am quite excited at the potential for increasing both happiness and productive capacity, although I know nothing about the implementation.

'3. Figure out how to measure subjective experience so we can better compare interventions, within and without mental health.

comment by Benjamin_Todd · 2017-11-22T22:53:11.787Z · score: 3 (3 votes) · EA(p) · GW(p)

Hey, on (1), cost-effectiveness estimates and wellbeing estimates are useful, but I'd also want to think more broadly about the INT framework side-by-side with global health, as well as other more qualitative arguments on each side.

Relatedly, I can imagine concluding that it's a big and neglected problem, but also one where clear, evidence-backed scalable interventions don't yet exist, so the top priority might be more research to develop better interventions. This perspective might get overlooked if you focus more on cost-effectiveness estimates, but seems pretty reasonable in some of these areas, such as mindfulness.

If that perspective is correct, then the question becomes is it better to scale up proven global health interventions, or do more research into mental health interventions?

comment by Elizabeth · 2017-11-22T23:02:47.915Z · score: 1 (1 votes) · EA(p) · GW(p)

...is it better to scale up proven global health interventions, or do more research into mental health interventions?

That's a great question I don't know enough to answer. I'd love to see general guidelines for deciding on investment in research versus boots on the ground work.

comment by MikeJohnson · 2017-11-20T20:46:51.805Z · score: 6 (6 votes) · EA(p) · GW(p)

This is a wonderful overview. I especially appreciated the notes about possible biases in each study.

My expectation is that the "mental health tech" field is also worth keeping an eye on, although it's often characterized by big claims and not a lot of supporting data. I'm cautiously optimistic that an app like UpLift (Spencer Greenberg et. al) might be able to improve upon existing self-administered CBT options.

There have also been a lot of promising developments in neuroscience and 'applied philosophy of mind', and if there are ways of turning these into technology, it seems plausible we could start to see some "10x results". Better ways to understand what's going on in brains will lead to better tools to fix them when they break.

The two paradigms I find most intriguing here are

  • the predictive coding / free energy paradigm (primary work by Karl Friston, Anil K. Seth, Andy Clark; for a nice summary see SSC's book review of Surfing Uncertainty and 'toward a predictive theory of depression' - also, Adam Safron is an EA who really knows his stuff here, and would be a good person to talk to about how predictive coding models could help inform mental health interventions)

  • the connectome-specific harmonic wave paradigm (primary work by Selen Atasoy; for a nice summary see this video&transcript - this has informed much of QRI's thinking about mental health)

I'd also love to survey other peoples' intuitions on what neuroscience work they think could lead to a '10x breakthrough' in mental health tech.

comment by RomeoStevens · 2017-11-20T21:23:25.902Z · score: 4 (6 votes) · EA(p) · GW(p)

Two areas I think are most promising off the top of my head (held lightly)

  1. Continuing connectome work with advanced meditators. This kind of research has been ongoing at various institutes for the last decade. It would be nice to get a consistent pipeline of funding to enable less stop-start.

  2. Triaging of people into mental health interventions. By paying too much attention to mean effect size in aggregates of treatment populations we are potentially ignoring large effect sizes in restricted treatment populations. Gathering data on outcome distribution shapes and attempting to do some hypothesis exploration on what hidden features are making certain people high responders to certain interventions could be incredibly high returns.

comment by MikeJohnson · 2017-11-20T21:42:28.072Z · score: 1 (1 votes) · EA(p) · GW(p)

I would definitely endorse these.

comment by Halstead · 2017-11-23T19:05:10.529Z · score: 4 (4 votes) · EA(p) · GW(p)

Thanks for this. Founders Pledge has recently completed a report on mental health and we found that Strong Minds' cost-effectiveness has increased significantly due to significant declines in cost. We have it at around the $220/DALY mark. Depending on how much you think DALYs underweight mental health, this makes Strong Minds look highly cost-effective. There is, I should note, large uncertainty, and their intervention is less well-tested than other global health interventions.

The report will be on our website in the next few months, but I'm happy to share it with anyone interested.

As we're recommending Strong Minds, this will probably mean that significant funds will be directed to them in the next year or so.

comment by egastfriend · 2018-04-26T01:32:06.495Z · score: 2 (2 votes) · EA(p) · GW(p)

Hi Elizabeth,

Thanks for writing up this review of Mental Health as an EA cause area! As you know this is an issue near and dear to my heart. You've done a great job summarizing many of the most interesting and important issues in this space.

I wanted to point out a few areas where I think this report could be improved:

DALY count: This article provides good reasons why mental health really repferents 13% rather than 7% of global DALY burden: https://www.ncbi.nlm.nih.gov/pubmed/26851330

Trace Lithium: I think it is important to distinguish between "Lithium in the Water Supply" as a research topic (looking at naturally varying levels of lithium) versus as an intervention. If we determine that the trace lithium hypothesis is correct, i.e. that lithium is a nutritionally necessary mineral that many people are deficient in, then the best intervention would be for the FDA to issue a Recommended Daily Intake so that it gets added to fortified foods, such as vitamins. This way, people can see when Li has been added to their food, and have autonomy over consuming it. Adding lithium to the public water supply would be ethically problematic, politically difficult, and unnecessary. Unfortunately, evidence for the trace lithium hypothesis has weakened since OpenPhil wrote their report, due to this study in Demark (however, the range of Li concentrations was limited): http://www.mdpi.com/1660-4601/14/6/627/pdf

Suicide and Crisis Hotlines: This is a promising area for research. I haven't seen any strong RCT's on these interventions yet.

Marijuana and Opioid overdoses: New evidence has come out since you wrote this post, showing a more complex relationship. The author of the study said, "Before we embrace marijuana as a strategy to combat the opioid epidemic, we need to fully understand the mechanism through which these laws may be helping and see if that mechanism still matters in today's changing opioid crisis.” See: https://www.rand.org/news/press/2018/02/06.html

MDMA for PTSD: While promising, I think the risk profile of MDMA and worldwide perception and political realities around it make it a less tractable intervention. I think Propranolol is more promising because it's already on the WHO List of Essential Medicines and very safe, as I argued in my report: http://www.harvardea.org/blog/2016/7/13/paf-mental-health-in-sub-saharan-africa

DARE: The bulk of evidence on the original DARE program showed that it had no effect -- I think it's an overstatement to say it increased drug consumption. It's also important to point out that DARE has been overhauled with help of the research community, and their new program, Keepin' it Real, has shown modest signs of success: https://www.scientificamerican.com/article/the-new-d-a-r-e-program-this-one-works/

Methadone: I haven't read Elizabeth Pisani's book, but I don't think it's fair to say that it doesn't reduce addiction -- it's more accurate to say it doesn't reduce dependence. Addiction is defined in the DSM-V as causing problems in the patient's work/personal life, so when patients are stabilized on methadone maintenance programs (as many are), working and living normal healthy lives, they are no longer considered addicted.

Looking forward to the next iteration of this! Eric

comment by MichaelStJules · 2017-11-22T01:39:50.399Z · score: 2 (2 votes) · EA(p) · GW(p)

Relevant recent systematic review:

Quality Assessment of Economic Evaluations of Suicide and Self-Harm Interventions: A Systematic Review.

http://psycnet.apa.org/record/2017-41357-001

PDF: http://psycnet.apa.org/fulltext/2017-41357-001.pdf

comment by pasha · 2017-11-20T20:43:45.216Z · score: 2 (4 votes) · EA(p) · GW(p)

I like this report and it's a good start. In some ways i wonder if even this report underestimates the real costs. Mass shootings, divorce, funding of crime, poor financial choices are things that come to mind as negative flow-through effects of poor mental health.

With that in mind, I find that it is difficult to even talk about mental health interventions without a good metric. Reducing number of suicides is great, but it's not going to capture large groups of people going through "slightly depressed" to "not depressed," unless the intervention is correlated with reducing suicides as well. Things like improving self-reported happiness are probably good, but it's not clear that's captures what we mean by mental health.

I feel that the next step in improving the situation is more along the lines of figuring out metrics that we can measure that specifically target mental health.

Similarly for interventions, there is probably a large number that are hard to evaluate at this point. Interventions are generally in two categories: biological and cultural with biological being the easy one. Things like diet, promoting better sleep / less screen time. Cultural would be more tracking how communities evolve and help / hurt mental health and what can be done to promote them.

comment by Elizabeth · 2017-11-20T21:28:03.685Z · score: 4 (4 votes) · EA(p) · GW(p)

Double checking that you saw the supporting doc on the difficulties in measuring mental health at https://acesounderglass.com/2017/11/20/measuring-the-impact-of-mental-illness-on-quality-of-life/

comment by pasha · 2017-11-20T22:55:42.757Z · score: 0 (0 votes) · EA(p) · GW(p)

Ah, did not see it. I think your conclusion there "None of these measurements met my goals of being easy to measure and capturing the entire impact of mental illness." is correct and it's probably worth thinking a bit about the metrics. That said, even improvement on an imperfect metric could do a lot of good.

comment by bradleyt · 2019-08-18T18:29:36.822Z · score: 1 (1 votes) · EA(p) · GW(p)

Thanks for sharing!

Are you aware of Metacognitive Therapy? It is not widely practiced, but it has some promising albeit limited evidence for it's efficacy: https://doi.org/10.3389/fpsyg.2018.02211

comment by KrisMartens · 2017-11-21T16:59:35.969Z · score: 1 (1 votes) · EA(p) · GW(p)

Great that mental health is getting more attention. Three random remarks that might be of interest:

(1) psychological treatments will probably evolve to become more transdiagnostic / process-based. For example Unified Protocol from Barlow, core principles in Acceptance and Commitment Therapy, the way the UCLA Depression Grand Challenge is taking shape, or the Research Domain Criteria. So most interventions described in this article are being dismantled which in combination with things like network analysis of symptoms (for example the things Eiko Fried is doing) should boost efficacy.

(2) The treatment gap between what works in research settings (efficacy) and what people really receive (effectiveness) is huge. Lobbying for initiatives like Improving Acces to Psychological Treatments in first world seems like a potential priority as well.

(3) About providing general psycho-education and media campagnes: I once saw an impressive talk by Jim White about Steps for Stress.

comment by Milan_Griffes · 2017-11-21T01:56:29.733Z · score: 1 (1 votes) · EA(p) · GW(p)

Great post; very excited to see more good work in this direction.

[rest of comment redacted]

comment by Elizabeth · 2017-11-21T02:51:00.990Z · score: 1 (1 votes) · EA(p) · GW(p)

Oops, thanks for the correction. Do you have those broken out separately?

comment by Milan_Griffes · 2017-11-21T17:37:55.589Z · score: 1 (1 votes) · EA(p) · GW(p)
comment by nomorestigma · 2018-10-23T16:26:38.730Z · score: 0 (0 votes) · EA(p) · GW(p)

Wow! You might write this as a "shallow review" but it looks quite comprehensive to me!

Due to my own struggles with mental illness (and my families) this has become an issue that I have a "sense of obligation" towards. (https://hbr.org/2013/04/find-your-moment-of-obligation). This article has helped clarify where I need to channel my "desire to help" most effectively. Thank you.

One side question as a researcher... is this part of a larger scholarly report? Something that might be published in a scientific (hopefully open-access) journal?

Again, thank you!

comment by HedvigeSciverit · 2018-09-11T09:26:41.963Z · score: 0 (0 votes) · EA(p) · GW(p)

Thanks for sharing.

comment by Jonas Vollmer · 2018-01-02T22:06:20.375Z · score: 0 (0 votes) · EA(p) · GW(p)

Great post!

A brief remark / recommendation: Consider replacing "first"/"third" world by "developed"/"developing" world or something more specific. The former terms are a bit dated and are sometimes seen as presumptuous.

(Random article that explains the difference in more detail: https://mic.com/articles/107686/why-you-shouldn-t-call-poor-nations-third-world-countries )

comment by Julio_Banfi · 2017-12-08T20:12:18.065Z · score: 0 (0 votes) · EA(p) · GW(p)

Great post, Elizabeth.

Have you looked at Dr. Davidson's Center for Mental Health? https://centerhealthyminds.org

At the center, they've been working on this kind of research for dacades: "Faced with mental and physical health challenges at a global scale, we conduct rigorous scientific research to bring new insights and tools aimed at improving the well-being of people of all backgrounds and ages."

Also, Dr. Davidson's recent book ("Altered Traits, Science Reveals How Meditation Changes Your Mind, Brain, and Body", coauthored with Daniel Goleman) seriously tackles meditation from the research-based perspective.

comment by DonyChristie · 2017-11-27T09:48:25.434Z · score: 0 (0 votes) · EA(p) · GW(p)

Did you look into coherence therapy or other modalities that use memory reconsolidation? It is theoretically more potent than CBT.

comment by ateabug · 2017-11-27T20:56:45.983Z · score: 2 (2 votes) · EA(p) · GW(p)

Could you provide any links to clinical trials that show coherence therapy to be effective compared to other therapies?

comment by Elizabeth · 2017-11-27T22:46:17.320Z · score: 1 (1 votes) · EA(p) · GW(p)

How scalable is coherence therapy? CBT is attractive not just because of the experimental backing but because it can be automated.

comment by EvanWard97 · 2017-11-24T18:21:16.400Z · score: 0 (0 votes) · EA(p) · GW(p)

Great work. I must admit that I am not very well read up on mental health, but it seems that the root cause of it is our lack of evolutionary fit with the current societal environment. To oversimplify, we aren't living in small tribes on the Savannah anymore. It seems to me like the most promising long term solution is genetic engineering us to be happier.

comment by Peter_Hurford · 2017-11-21T21:57:50.169Z · score: 0 (0 votes) · EA(p) · GW(p)

Do you know why StrongMinds chose the intervention that they did? Do you think there's a cost-effective way to administer CBT in the third-world?

comment by Elizabeth · 2017-11-21T22:32:06.927Z · score: 2 (2 votes) · EA(p) · GW(p)

According to the person I talked to, StrongMind's chose their intervention because it was the only one that had experimental backing equivalent to what J-PAL does.

Unorganized thoughts on CBT for the bottom billion: Poor Americans complain that it implicitly assumes the problem is in your head and is unhelpful if there's an actual problem in your life. I'd guess this would be worse for the bottom billion. I'd expect significant changes to have to be made to adjust to local cultures. The maximum cost would be in the ballpark of StrongMinds. The minimum cost would be much lower, I expect CBT to be more amenable to scaling via phones. I am pretty skeptical of automated CBT. I think it follows the letter of CBT but is missing some implicit step that is actually what is helpful. This is mostly an intuition. OTOH, it could have a very low success rate and still be very helpful if enough people tried it and the cost of trying was low. CBT has been getting less effective as time goes on, potentially because the best insights have made their way into popular culture. I wouldn't expect that to be true for the bottom billion, which would increase its effectiveness.

So I think my ultimate answer is "CBT is a good jumping off point to look for something that would indeed be very cost-effective in the third world."

comment by cubup · 2017-11-20T22:52:29.505Z · score: -2 (6 votes) · EA(p) · GW(p)

i like this post

comment by Maxdalton · 2017-11-22T08:23:21.188Z · score: 2 (2 votes) · EA(p) · GW(p)

Hi cubup, Just in case you're a newbie who doesn't understand why you're being downvoted: If you just want to express approval/disapproval for a post, you can use the thumbs up/down at the bottom of articles. Please try to keep comments for something more substantive. :)