AMA: Sean Mayberry, Founder & CEO of StrongMinds

Thanks for these questions! I appreciate the time you took to really look at our data, and I think some of the questions will help us ponder what we need to be looking at next within StrongMinds. Please note, as the Founder, I'm not a researcher or clinician by trade, so my answers may not be as granular as you would hope, but I'll do my best to respond. I'm going to tackle the first four tonight.

1. a. The NNTs could be different due to a variety of theoretical factors. NNTs are really only as good and accurate as the data provided. We are planning an RCT for 2023, so hopefully, we will have more to consider and dig into once those numbers are available. b/c. Yes, the numbers are surprising. As I've mentioned in some of the other responses, I largely think the success has to do with the interpersonal nature of IPT and how it works within the community-centered culture of Uganda and Zambia.
2. I believe the 10% figure is part of the HLI analysis, and I am not an expert on that, so I'll let their team speak to that or let the numbers speak for themselves. 
3. An RCT certainly could have been done as a pilot, but they are pretty costly to complete, and at the time, StrongMinds was just finding its footing and searching for funders. I was working as a volunteer at StrongMinds for the first 18 months of operation. 
4. Our facilitators are all lay community members. In Uganda, 100% of our facilitators are Ugandan. In Zambia, they are all Zambian. They don't need to have a college degree in Psychology; in fact, they don't even need to have a high school degree. The most critical factor when we are interviewing potential facilitators is their empathy level. We have found that the higher their empathy level, the better they are as facilitators. 

I can maybe help with question 5, since the $170 figure originates from my analysis. 

I finalized the cost figures during COVID when their cost figures were very high ($400 per person). I tried to project what they'd be over the next 3 years (starting in 2020) and assumed it'd come down, but the costs have come down faster than I imagined. They now say they expect 2022 to cost 105 USD per person treated. 

They regularly update their cost and expense figures in their quarterly reports. 

And here's the general breakdown of their expenses according to their 2021 tax returns (page 10). 

Hi Yonatan. Thanks for the questions. I wouldn't quite say we solved it, but we have found a solution that has had tremendous results in Uganda and Zambia. There are probably a few reasons for this.  Most of the communities we work in are very close-knit and interpersonal, so the group talk therapy model of IPT-G works well. Additionally, around 85% of women in sub-Saharan Africa don't have access to quality mental health care. There is a huge treatment gap, for instance, Uganda has approximately 30 trained psychiatrists serving a population of 45M, so we are also filling a dire need by providing these free services using lay community health workers. The symptoms of depression are still not commonly known in Uganda and Zambia, and many people think they are just fatigued, sick, or just unmotivated/lazy, so discovering that there is a way to treat their symptoms and that there are other people experiencing this too is life-changing. Many women in therapy groups form a bond and continue to meet long after therapy ends. They now have a new support system and are no longer isolated. All of these factors play a role in our success. 

The program model can be replicated in other geographical locations, and IPT has been shown to work well cross-culturally. We are currently exploring an American pilot where the need is also extreme in underserved BIPOC communities. Our pilot is happening in the Newark, NJ area just outside of NYC. That said, we have to do quite a bit of work to determine how western preferences fit into this, and we are collecting data from some initial groups now. 

StrongMinds therapy model is based on an RCT from 2002 in Uganda. It has shown to be a highly effective way to reach women in underserved and remote areas that would otherwise not have access to mental health treatment options.  

I’m glad this is (currently) the top-voted comment. I’ve reviewed the evidence StrongMinds offers up and find it relatively persuasive. But every page yells “offer this in wealthy countries and you’ll do good and do well at the same time.” A quick google suggests that the global ‘market’ for mental health is in the order of $400b. And this intervention seems significantly better than anything else currently in the market. Shouldn’t this be a multi-billion-dollar company being snapped up by pharma giants? 

I guess that outcome seems so wild that it generates doubt about the original claim. I’d like to know the additional detail that contextualises that. 

I think it would be useful to know the percentage of women with depression who we would expect to be depression-free after a six month period without any intervention. 

There's a sister org working on it About Depression - StrongMinds America

Thank you! We try to be open to challenging questions at StrongMinds. It's part of our culture, and we think asking tough questions can lead to better results. 

On (2):  Here's the section on social desirability bias from HLI's cost-effectiveness analysis.

Haushofer et al., (2020), a trial of both psychotherapy and cash transfers in a LMIC, perform a test ‘experimenter demand effect’, where they explicitly state to the participants whether they expect the research to have a positive or negative effect on the outcome in question. We take it this would generate the maximum effect, as participants would know (rather than have to guess) what the experimenter would like to hear. Haushofer et al., (2020), found no impact of explicitly stating that they expected the intervention to increase (or decrease) self-reports of depression. The results were non-significant and close to zero (n = 1,545). We take this research to suggest social desirability bias is not a major issue with psychotherapy. Moreover, it’s unclear why, if there were a social desirability bias, it would be proportionally more acute for psychotherapy than other interventions. Further tests of experimenter demand effects would be welcome. 

Other less relevant evidence of experimenter demand effects finds that it results in effects that are small or close to zero. Bandiera et al., (n =5966; 2020) studied a trial that attempted to improve the human capital of women in Uganda. They found that experimenter demand effects were close to zero. In an online experiment Mummolo & Peterson, (2019) found that “Even financial incentives to respond in line with researcher expectations fail to consistently induce demand effects.” Finally, in de Quidt et al., (2018) while they find experimenter demand effects they conclude by saying “Across eleven canonical experimental tasks we … find modest responses to demand manipulations that explicitly signal the researcher’s hypothesis… We argue that these treatments reasonably bound the magnitude of demand in typical experiments, so our … findings give cause for optimism.”

Thanks for your kind words and for the great questions!

1. The relationship between poverty and mental health disorders, including depression, is complex. Poverty exacerbates depression, and depression, alongside other mental health disorders, can drive people further into poverty through reduced productivity, decreased income, and isolation. (Lund et al. 2011) But it is incorrect to conclude that poverty on its own causes depression. If it did, we would see rates of depression at 100% rather than 25% in the slums of Kampala. Our model looks at four distinct triggers for depression: grief, life changes, loneliness/isolation, and conflict. Interestingly, we see from our well-being indicators that many times, restoring a woman's mental health can increase her productivity and livelihood; for instance, 16% of our former clients reported increases in work attendance after the conclusion of therapy. 
2. Yes, in self-reported data, we have to be very careful to ensure we measure correctly and there aren't existing biases or misrepresentations. We work directly with an external firm to help with this. They conduct our endline evaluations. As mentioned above, we also look at well-being indicators to help demonstrate our impact, such as a 13% increase in family food security, a 30% increase in school attendance, and a 28% increase in women feeling socially connected. 

Both are true! Numerous studies have shown that when you help an African Mom, the downstream effects are significantly more substantial. Globally, women have a depression rate of 1.5 times higher than that of men. An African woman with depression, compared with her healthy peers, suffers greatly: she is less productive,  has a lower income,  and has poorer physical health. If she is a Mother, the negative impact extends to her entire family. Research shows that children of depressed Mothers are more likely to have poor health,  struggle in or miss school, and suffer from depression themselves. 

Furthermore, because depression impairs the ability to focus and concentrate, depression sufferers do not respond to health initiatives or livelihood trainings, rendering these programs less effective. 

This impaired ability to function in day-to-day life creates profound hardship in Uganda and Zambia,  where life is community-centered and reliant on each person fulfilling her role and where depression carries a great stigma. When a woman cannot perform her social responsibilities, she can become a target of criticism and social exclusion. Women in these communities also often have far less access to resources. 

I suggest doing your research (the information we received from the researchers who conducted the initial John Hopkins/Columbia University RCT was instrumental to our success.) Also, know your audience. We try to consider each woman in our therapy program's perspective. How did she hear about us? How is she accessing information about the program? The more demographic information you have about your audience, the better you can target your outreach/messaging and achieve results. Other considerations are what staffing is needed to make the product or tech run? And what frameworks need to be in place? We had to do a lot of this evaluation ourselves when switching our model to teletherapy during the pandemic. The model, resources, and modes of communication available will all have a huge impact on the specific strategy. 

Thanks so much for your kind words and for following our work! I appreciate your comment about the incredible impact mental health can have. We've certainly seen it change women's lives far beyond what we could have predicted, such as helping a woman's children eat more meals a day or even helping individuals with HIV adhere to their antiretroviral treatments more regularly. 

1. We completely switched to a teletherapy model during the COVID-19 lockdowns in Uganda and Zambia, which required a lot of creative thinking on a short timeline. This made it somewhat tricky to reach our target demographic since many women share a phone with their family or neighbors (and some don't own a phone at all.) Fortunately, the depression-free rates were comparable to in-person group therapy, and some ultimately preferred the flexibility it offered. We usually work in communities, offering therapy directly where the women live to make access easy (our motto was often to diagnose on a doorstep, treat under a tree.) We had to reach new clients using things like radio ads, social media, and a mental health WhatsApp-based chatbot to help ensure resources were available as often as needed. You can read more about our key learnings from the COVID-19 pandemic here. 
2. Like most in the mental health field, we saw a sharp increase in the need for services, particularly during the lockdowns. Unfortunately, since then, we have seen other climate-related humanitarian crises causing things like flooding and drought, undoubtedly worsening mental health conditions. Additionally, Uganda currently has some Ebola lockdowns in place, stressing already thinned health resources. StrongMinds has made ourselves available to support in these cases. We know mental health care is critical during high-stress times, and rates are only projected to increase in the coming decades. The good news, though, is, as you've eloquently stated, the interpersonal nature of group talk therapy enhances outcomes. We've seen that 72% of former clients we spoke to in Uganda were still in touch with their group mates. This extends years later in many cases. 
3. Absolutely! I've often said that the hardest part of our job is finding depressed individuals and getting them into a group. Depression can make simply getting out of bed a challenge, so this can be tricky. The group model works well to help with this scenario, though, because group members can hold each other accountable and check in on each other. Uganda and Zambia still have many stigmas associated with mental health, so advocacy and psychoeducation are critical to our work in-country. You can read more about the complete therapy assessment process and how we work to educate about mental health here in this Psychology Today article by our talented Uganda Country Director/Clinician, Tina Ntulo. 
4. Similarly, a small door-to-door study led by StrongMinds in Mukono District, Uganda, estimated that the prevalence of moderate to severe depression in adult women was about 20%. We also have about 85% of individuals with no access to other forms of treatment. IPT works particularly well in these settings and is currently a WHO-recommended first-line treatment for depression in low-resource settings. Other forms of community-based models using a rights-based approach are a great way to empower individuals to seek recovery and focus on the value of human rights within the mental health space. 

Hi John! I have not forgotten this question. I aim to have an answer for you by the end of the week. I wanted to wait until our CFO had the opportunity to review to ensure we have the most recent figures for you. I'll be back in touch on this very soon. Thanks for your interest! 

StrongMinds seeks to treat 300,000 women and adolescents between 2022 through 2024. To do that, we need to raise $30M U.S. dollars. To date, we've raised about $13M, which leaves us at a shortfall of $17M. So there is lots of room for more funding!

In 2022 we expect the cost to treat one patient will be $105 USD. By the end of 2024, we anticipate the cost per patient will have decreased to just $85. We will continue to reduce the cost of treating one woman even while our numbers increase. This is through effective scaling and continuing to evaluate where we can gain more cost savings. A donation to StrongMinds will be used as effectively and efficiently as possible. And when you think about what it costs for therapy in the United States, to spend just $105 and treat a woman for depression is a pretty incredible feat. 

Currently, StrongMinds is actively looking to hire for a few positions listed here. We are growing and are always looking for smart, ambitious, and creative people to join our team. We encourage everyone to follow us on LinkedIn for our most up-to-date job openings. At this time, we currently do not use volunteers. 

Great questions! I should probably do a bit more reading on both topics before making a definitive statement, but just like the emphasis on well-being from Happier Lives Institute, I think considering the suffering risk of populations is a high moral priority. Mental health is an investment in the betterment of all areas of life. We see it can increase productivity, the number of meals a family eats, and the amount of school children attend. It impacts all areas of life and health, and similarly, restoring mental health creates thriving communities and stronger economies. From the longtermism philosophy, I think there is much to consider outside of simply eliminating existential threats and improving humanity. The results of climate change are already devastatingly impacting some of the communities we work in, which has serious implications for mental health and overall well-being. If we genuinely wish to eliminate suffering, we must address the crises and unrest at the root of the depression triggers. 

Hi, harriet! Thanks for the questions! Yes, there are advantages and disadvantages to both individual and group therapy, and as you mentioned, cost certainly favors the group model. We can offer a woman an entire course of treatment for $105. In terms of patient outcomes, StrongMinds doesn't utilize individual therapy, but some studies have shown that effectiveness overall is pretty similar, and it really comes down to individual (and sometimes cultural) preferences to determine what type of therapy is best. I hope that helps!

In terms of SSRIs, yes, they can certainly be effective. In some cases where we think the client is a risk to themselves or others during therapy pre-screening, we refer them to where they have access to other methods, including SSRIs or other prescription options. That said, there are some significant challenges with the availability of SSRIs, given the treatment gap and the fact that everyone may not have the access needed to get to a trained psychiatrist/psychologist or nurse to prescribe them. This is one of the reasons the WHO recently cited and recommended community-based models and methods using lay community workers rather than trained mental health professionals as a key way to meet the growing need for services. 

In terms of cost-effectiveness, prescribed medication is reasonably affordable, but the cost can add up over a lifetime of use. For $105 USD on our end (and entirely free for the women we treat), we can provide long-term depression-free rates. Our results show that for every woman who restores her mental health, four additional members of her family feel the benefits. The HLI cost analysis looks at the benefits for the whole family as well as some of the long-term impacts as well, which is what makes our model so cost-effective.