Nov 20, 2017
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.
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):
American Foundation for Suicide Prevention: Works to understand and prevent suicide by supporting research looking at the causes of suicide, helping those who have suicidal thoughts or those who have lost someone to suicide, and working with federal and state government on policies to prevent suicide and care for those at risk.
2015 Budget: $17.7 million
Brain & Behavior Research Foundation: Grant making organization focused on cause and treatment of mental disorders.
2015 Budget: $23.9 million
2015 Budget: $5.2 million
Multidisciplinary Association for Psychedelic Studies studies currently illegal drugs (MDMA, marijuana, and psychedelics) for medicinal use.
2016 Budget: $4.4 million
Many first world national governments both have research arms and treat mental illness as part of their public health structure, e.g. the US’s National Institute for Mental Health.
Suicide Prevention Hotlines: This includes the well known Lifeline, as well as many smaller programs aimed at specific demographics like sexual assault victims or LGBT people.
Many therapists in the US will work on a at sliding scale for low-income patients.
Many governments’ legal systems, in the form of punishment for drug use and sale.
Based on shallow googling, most anti-substance-abuse programs are local. These are individually small but abundant, making it difficult to determine their overall scope.
Basic Needs: builds capacity of local medical professionals to treat mental illness, and supports participants in gaining a livelihood. As of July 2017, Basic Needs had merged with CBM UK, a charity targeting a range of disabilities.
Strong Minds: Creates group therapy sessions, run by former participants. While I have not verified the veracity of their claims, they mention both scalability and monitoring/evaluation on their website, indicating potentially high value alignment. In discussion, they mentioned training other NGOs on their model and that they would be eager to do this more; one potential intervention would be to simply copy their model and bring it to another country. 201(6?) budget: $2.0 million.
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?
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 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.
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
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.