This is a summary of a new report from the Happier Lives Institute.

Authors: Caitlin Walker, Clare Donaldson, Michael Plant.

Executive summary 

This report investigates the global burden of mental illness. It sets out how big the problem is, how much spending it receives, and how those resources are allocated. It then focuses specifically on what can be done to reduce anxiety and depression in low-income countries—the assumption is that this is the part of the problem where additional resources would have the highest impact. It closes by outlining some promising donation options and career paths in the area, but does not attempt to evaluate which of these options are the most impactful, or to compare mental health to other possible global priorities—that requires further research, which HLI is undertaking regarding donations. We expect this report will be most useful for those considering putting their career or charitable donations towards improving global mental health and who therefore want to gain a better understanding of the nature of the problem and what could be done about it.

What’s the problem?

Mental illnesses are among the worst, if not the worst, of life’s common misfortunes. Depression and anxiety are associated with bigger reductions in life satisfaction than debt, divorce, unemployment, Parkinson’s, or Alzheimer’s. All over the world, those with mental illnesses suffer human rights abuses; these can be severe as being chained or caged.

Around one in every nine people lives with a diagnosable mental health disorder. These disorders are responsible for 5% of the global burden of disease, as measured in disability-adjusted life years (DALYs), and 15% of all years lived with disability. These figures are likely to be a substantial under-estimate for several reasons, for instance, that suicides and self-harm are not attributed to the burden of mental health disorders.

The vast majority of people living with mental health disorders, even in rich countries, do not receive treatment. The issue is even more acute in LICs, where mental health spending amounts to US$0.02 per person per year. In terms of development assistance, HIV receives 150 times more funding, per DALY lost to the problem, than mental and substance abuse disorders combined.

Effective interventions to improve mental health exist and can be deployed at scale. The 2016 Disease Control Priorities report noted a range of effective interventions for preventing or treating mental illnesses, and for promoting good mental health. Although there are few mental health specialists in low-income settings, one tried-and-tested way to scale-up interventions is ‘task-shifting’, where lay health workers provide therapy under the training and supervision of professionals.

While several treatments are deemed cost-effective (according to conventional standards in healthcare) the evidence-base for cost-effectiveness in low-income settings is limited. Not only are there few estimates of cost-effectiveness, these are mainly from high-income country contexts; almost no outcomes are measured in terms of subjective well-being. 

Current mental health budgets could be spent more effectively. Around 80% of mental health spending in low- and middle-income countries (LMICs) goes towards psychiatric hospitals. Mental health experts argue that carefully moving to community-based care would lead to better outcomes, given fixed budgets. Further improvement could come from integrating mental health services within primary healthcare and increasing the (limited) access to cheap pharmaceutical treatments, such as antidepressants. 

Stigma and misunderstanding are a major problem. These are commonplace among the general public, policymakers, and health professionals. This causes an unfortunate cycle: individuals are unwilling to seek treatment or may not even know treatment is possible; policymakers, faced with this lack of demand, prioritise other matters; as result, stigma and misunderstandings persist.

What can be done?

In light of the barriers and solutions identified from the literature, we suggest several broad avenues through which donors could fund useful work or individuals, through their careers, could undertake this work themselves. We do not attempt to prioritise between these, or between mental health and other problems; that was outside the scope of this project and is a topic for further work. We encourage interested readers to conduct their own, supplementary research.

Research

There are many potentially valuable research directions. Examples include: identifying root causes of mental illnesses; improving preventive interventions; advancing the scale-up of existing treatments; and developing new treatments or improving existing ones.

Intervention delivery 

This refers to providing individuals with interventions that prevent or treat mental disorders or promote good mental health. This direct work could be carried out by funding, founding, or joining effective non-profit or for-profit organisations. Donation advice in this area is currently quite limited; the Happier Lives Institute is working to provide some in the near future (see section 7, particularly 7.2).

Policy and advocacy work

Mental health policy and advocacy work could raise public awareness of mental health disorders and press decision-makers, such as those in governments, to provide more and better services. This might include grassroots campaigning, journalism, lobbying, or work in think-tanks at a national or international level. 

The global burden of mental illness is substantial and receives scant attention. Fortunately, there are a range of ways to make progress on this problem and help people to live happier lives. We expect that improving mental health could be among the most impactful options for donors and for individuals seeking to do good with their careers.

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I've been pretty skeptical that mental health is something EAs should focus on. One thing I see lacking in this report (apologies if it's there and I didn't find it) seems to be a way of comparing it to alternatives, since I don't think that mental health is a source of suffering for people is in question, but whether it's compares favorably to other issues.

For example I'd love something like QALY analysis on mental health that would allow us to compare it to other cause areas more directly.

Thanks for raising this - comparing things is a cause very close to my heart!

First, the report wasn't trying to compare the importance of mental health as a cause area to other things, so I understand that you didn't find that, because it wasn't central.

Second, the report  (p8) does compare the impact of depression and anxiety to various other health conditions, as well as to debt, unemployment, and divorce in terms of 0-10 life satisfaction, a measure of subjective well-being (SWB) - the other main measure of SWB is happiness. We, as in HLI, are pretty enthusiastic about comparing different outcomes in terms of SWB rather than anything else, e.g. QALYs. The obvious issue, if you use QALYs, is it's a measure of health, and even if you thought it was an excellent measure of the impact of health on well-being, you still need to compare health to non-health outcomes. 

We mentioned SWB in a recent post about Our 2020 Annual review, this post about using SWB to compare averting poverty to saving lives, I argue explicitly for in this 2018 post, and it's raised in so many other places I'm starting to feel embarrassed about repeating myself, which is why it wasn't featured prominently here(!)

Third, the report also mentions (p26) that I've previously done a fairly basic analysis, including in my PhD, using SWB to compare a mental health charity (StrongMind) to those recommended by GiveWell - on that mental health looks rather promising. Further, it notes (at p36) that HLI is now working on a more empirically sophisticated SWB analysis of the same type. We have some provisional results for this latter analysis and should be putting out those reports within a couple of months, and which point you are welcome to dive into that comparison!

Speaking of comparing to alternatives, I can't resist making a pedantic note for posterity that the fact about "per DALY lost, spending on HIV is 150x higher than spending on mental health" is not necessarily a sign of irrational priorities. After all, HIV is contagious in a way that mental health problems mostly aren't!

I'm sure Taiwan is spending much more on covid-19 prevention right now than they are on cancer treatment per DALY being lost (they have almost no covid cases but are willing to constantly apply severe anti-covid restrictions), but it's a rational decision because covid has the potential to rapidly spiral out of control in a way that cancer can't do.

I don't think the report was trying to use the fact as some kind of instant knockdown argument in favor of mental health vs HIV spending -- they were just using it as an illustrative comparison (which it is) to a well-known existing category of international health spending, to show that mental health spending is much smaller. So, the report is totally cool by me (and indeed we probably should be spending more on mental health globally, regardless of whether it's a #1 EA issue or a lower priority). I just wanted to make a note here for anyone interested in the 150x fact in the future.

that the fact about "per DALY lost, spending on HIV is 150x higher than spending on mental health" is not necessarily a sign of irrational priorities

I agree! At the start of section 4, on neglectedness - the one which later compares HIV to mental health spending - we make the same point (emphasis added):

In terms of national spending, in every country the proportion of the health budget spent on mental healthcare and research is disproportionate to the burden of mental disorders (see figure 4) (Patel et al., 2018). To be clear, this by itself does not show more should be spent on mental health, if the aim is to have the biggest impact using scarce resources: if interventions in other areas were more cost-effective, then this allocation would be justified. However, as we go on to argue, it seems likely mental health has been unduly neglected due to reasons such as stigma.

Sort of aside: there is this ongoing confusion inside the EA community about the importance of 'scale', 'neglectedness' and 'tractability', something that's been discussed on this forum before - see e.g. this summary of two chapters from my PhD thesis. I recommend that people think of scale (size of a problem) and neglectedness (resources going to a problem) as background information that might later be relevant to the cost-effectiveness of a  problem, but that they don't by themselves tell you anything about cost-effectiveness. 

Nice. Foolish of me to nitpick an executive summary -- it's a summary!

No problem. It's always a challenge that you want to put the attention-grabbing stuff at the top whilst knowing that you can't properly caveat it and many won't read anything else!

Terrific overview! I'll offer some feedback with the hope that some of it may be helpful:

Big Picture Thoughts

  1. In general, I thought the report did a great job summarizing some of the major themes/ideas that are fairly well-established in global mental health. I wonder if it could be useful to include a section on more experimental/novel/unestablished/speculative ideas. Sort of like a "higher risk, higher potential reward" section.
  2. Relatedly, I'd be interested in seeing bolder and more specific recommendations for future work. As an example, Box 2 ("Promising Research Directions") lists important goals, but they're too broad to really know how to act on (e.g., "improve treatments and expand access to care."). I'd be more curious to see HLI's subjective opinions on the most impactful next steps (more similar to the list of project ideas that you have, rather than the goals in Box 2).
  3. I'd love to see more analysis on key issues/controversies (see last section for examples).

Potentially useful points that I didn't see in the report:

  1. A lot of suffering is caused by subclinical/subsyndromal mental health problems. In the case of mood disorders, "subsyndromal symptoms are impairing, predict syndrome
    onset and relapse, and account for more doctor’s visits and suicide attempts
    than the full syndromes." (Ruscio, 2019). This point is especially important because there are debates about how funding should be allocated (e.g., how much should we spending on treatments that target people with diagnosable disorders vs. mental health promotion strategies and prevention programs that reach broader audiences?)
  2. Recent work has suggested that the "latent disease" view of depression (and other mental disorders) may be flawed (e.g., Borsboom, 2017). A related body of work has suggested that some depressive symptoms may be more impairing than others (e.g., Fried & Nesse, 2014). This could have important implications for measuring the effectiveness of interventions-- e.g., estimating SWB weights for each symptom, rather than using sum-scores.
  3. The evidence on task-sharing/task-shifting is strong, so I understand why you spent a lot of space covering it. At the same time, it could be useful to spend more time discussing some of the more novel approaches. Some examples include unguided self-help interventions and single-session interventions (Schleider & Weisz, 2017). Although the evidence for guided interventions and longer interventions is stronger, unguided interventions are substantially cheaper. This might make them more cost-effective, even if longer/guided interventions are more effective (discussed further in this preprint).
  4.  The digital interventions studied in meta-analyses and reviews are very different than those that have been disseminated widely. We know a lot about the effectiveness of digital interventions developed by professors, but much less about the effectiveness of Headspace, Calm, and other popular apps (Wasil et al., 2019).
  5.  There's are some important gaps in the digital mental health space: popular interventions tend to focus on relaxation/mindfulness and rarely include other empirically supported treatment elements (Wasil et al., 2020). This reminds me that I really should write up a digital mental health forum post at some point :) 

Examples of questions/controversies that HLI could address:

  1. Broadly, what does HLI see as some of the most important open questions in the mental health space? 
  2. What content should be included in interventions? Does HLI believe that specific elements should be the focus of interventions? Or are common factors driving effects?
  3. Which delivery formats be used? Is HLI optimistic or pessimistic about unguided self-help interventions? Are they likely to be more cost-effective than task-sharing interventions?
  4. Does HLI see mental disorders as diseases, networks of symptoms, or something else? Do you think this matters, or not really?
  5. Broadly, what does HLI think that a lot of people interested in mental health "get wrong" or "don't yet know" about the most cost-effective ways to make an impact?
  6. How long do the effects of interventions last? How should the uncertainty around this estimate affect our cost-effectiveness calculations? (assuming that the effects of an intervention will last <1 year seems like it would yield radically different conclusions than assuming it would 1-3 years, 3+ years, 10+ years 30+ years, etc.)

I hope that some of this was helpful & I'm looking forward to seeing future reports!

I am so excited I am about this report. It does such an excellent job at communicating a very complex - and at times confusing - topic such as mental health. I'm at least still struggling when talking to people about mental health and trying to summarize all the important aspects of if so I'm looking forward to sending them to this report and including it in our local career guide for EA Denmark. :) 

Hi Carmen, I'd be interested to read the local career guide of EA Denmark, especially if it has advice specific to mental health careers! 2 of our volunteers in EA Philippines are writing a career guide/review on becoming a psychologist to improve people's mental health in the Philippines. Our volunteers and I also worked on this problem profile on local mental health (and the full paper is here), if you'd be interested in reading that.