[Has anyone from GiveWell looked into mental health interventions? I couldn’t find an intervention report on their website but I’d be interested to know whether they have any informal take on it.]
At first blush this is pretty intriguing, especially the following points:
Apparently, people’s prediction about how bad depression would be compared to, e.g., severe pain is off by a factor of about 10, because hedonic adaptation applies to severe pain but not to depression. This biases DALY burden and cost-effectiveness statistics against mental health interventions.* (EDIT: not sure I buy this anymore; the “established” psych research is more questionable than I thought. See convo with Lila below.)
Note that despite this bias, unipolar depressive disorders incur the 9th biggest DALY burden of any disease according to the Global Burden of Disease 2012 update.
Most developing countries spend ~nothing on mental health and there is only one large charity working on it.
Other things this makes me wonder:
Where (geographically/demographically) is the DALY burden of depression/unhappiness concentrated? This would seem to have strong implications for where work should be focused. E.g., anti-depression smartphone apps developed in the US are unlikely to transfer well to India.
What is the actual effect size of CBT run “in the wild” via a scalable delivery mechanism like an app? How much of depression can we expect it to mitigate? Is the main problem to solve here finding a good intervention, or distributing it (i.e. getting people to use the CBT app or whatever)?
Have other (non-depression-related) interventions aimed directly at developed-world quality of life been tested? For instance, people notoriously neglect the effect of having a long daily commute on their happiness, and I suspect something similar applies to exercise and to food quality (at least, it does for me).
BTW, one note on the paper: you remark that “[a billionaire] should also run randomised controlled trials to assess how much happiness is increased by anti-poverty and anti-malarial interventions”—in fact, you can achieve a lower bound on the happiness increase of anti-malarial interventions because the main mechanism by which they reduce DALY burden (at least in GiveWell’s cost-effectiveness analysis) is by reducing mortality. Unlike severe pain, one cannot hedonically adapt to being dead, so anti-malarial interventions (and other mortality-reducing interventions) should have less of the 10x bias than e.g. cash transfers.
*I’m not incredibly confident in this argument; determining the actual quality of life burden here seems like a pretty subtle measurement problem of which I’d love to see a more thorough treatment than the paper provides, since it’s really the crux of the quantitative argument.
What is the actual effect size of CBT run “in the wild” via a scalable delivery mechanism like an app? How much of depression can we expect it to mitigate? Is the main problem to solve here finding a good intervention, or distributing it (i.e. getting people to use the CBT app or whatever)?
From what I can tell, the problem is more with outreach and retention than with effectiveness. Most of what I’ve read shows that computer based cognitive behavioral therapy (cCBT) is as effective as in-person CBT for anxiety and depression in the context of a RCT. But “in the wild”, rates of adherence drop considerably, with estimates of 0.5% and 1% completion in the only two published studies I could find [1,2].
If your server time and ongoing development costs are low enough, though, cCBT could still be a cost effective approach despite poor retention. This assumes that those that fail to complete the training aren’t harmed, but evidence seems to suggest that even partial completion is helpful [1,2]. Note that in study [1], about 15.6% completed 2 or more of the 5 modules, so a larger portion of people at least partially complete the training. I haven’t done a $/DALY estimate, but it would be fairly easy to come up with one with the results from study [1].
[1] A Comparison of Changes in Anxiety and Depression Symptoms of Spontaneous Users and Trial Participants of a Cognitive Behavior Therapy Website. http://www.jmir.org/2004/4/e46/
[2] Usage and Longitudinal Effectiveness of a Web-Based Self-Help Cognitive Behavioral Therapy Program for Panic Disorder. http://www.jmir.org/2005/1/e7/
[Has anyone from GiveWell looked into mental health interventions? I couldn’t find an intervention report on their website but I’d be interested to know whether they have any informal take on it.]
Yes, but not formally. I’ll ask Howie if he’d like to comment on this post.
I wouldn’t expect people to be able to adapt to severe pain, not when you consider the evolutionary advantages of always taking your hand out of the fire. I’d expect people to die before they got used to pain.
What is going on is that mental pain may have a bigger impact on your happiness then physical pain and more than we imagine it does. I.e. chronic depression is worse than chronic lower back pain.
(You might reply that this is unfair because mental pain and happiness are basically the same thing: i.e. it’s obvious being unhappy has a bigger impact on happiness than just being in pain, so you’ve just measured the same thing twice. What you’d really want is data which showed the impact different health states have on people’s emotional experience/moods (which is what I take happiness to be). Nevertheless given that depression/anxiety seems to be lots of negative mental states, whereas chronic pain isn’t, that’s still a point in favour of depression/anxiety being where the unhappiness is.)
And yes, so I think depression, which already looks bad on DALYs, is much worse even than that.
Also, it seems that mental health issues are all over the world in a way that, say, malaria is quite concentrated. That’s why I say it’s possible mental health interventions may be more effective in developed rather than developing countries—people have more technology are greater familiar with mental health.
I can’t tell you what the ‘in the wild’ effect size is because I don’t know it and I don’t think it’s been tried. That’s why I suggest a billionaire tests it to find out! The evidence is the CBT works (remedies about 50% of cases of depression) so I’d say the challenge is more getting it to people and getting them to use it.
Developed world happiness interventions? I’m not sure what you mean. Some people in some governments are beginning to think explicitly in terms of happiness, but it hasn’t really caught on.
On the death thing, we have different intuitions. In your parlance, I’d say you adapt totally to being dead: there’s no you after death for anything to be good or bad for! So all this analysis is very sensitive to philosophical issues.
I wouldn’t expect people to be able to adapt to severe pain, not when you consider the evolutionary advantages of always taking your hand out of the fire. I’d expect people to die before they got used to pain.
Sorry. Severe pain may have been a bad example. Other high-DALY-weight conditions do seem to show hedonic adaptation though, e.g. paraplegia (see my response to Lila for sources).
Sorry. Severe pain may have been a bad example. However, for instance, paraplegia does exhibit hedonic adaptation (source) despite having a disability weight of 0.57 (source).
I’m not sure what you think this meta-analysis contradicts. Could you please be more precise?
Card on the table, I’m more interested in ‘affective well-being’ than ‘cognitive well-being’ as they call it—i.e. ‘happiness’ rather than ’life satisfaction—and I take the meta-analysis as being broadly in my favour.
[Has anyone from GiveWell looked into mental health interventions? I couldn’t find an intervention report on their website but I’d be interested to know whether they have any informal take on it.]
At first blush this is pretty intriguing, especially the following points:
Apparently, people’s prediction about how bad depression would be compared to, e.g., severe pain is off by a factor of about 10, because hedonic adaptation applies to severe pain but not to depression. This biases DALY burden and cost-effectiveness statistics against mental health interventions.* (EDIT: not sure I buy this anymore; the “established” psych research is more questionable than I thought. See convo with Lila below.)
Note that despite this bias, unipolar depressive disorders incur the 9th biggest DALY burden of any disease according to the Global Burden of Disease 2012 update.
Most developing countries spend ~nothing on mental health and there is only one large charity working on it.
Other things this makes me wonder:
Where (geographically/demographically) is the DALY burden of depression/unhappiness concentrated? This would seem to have strong implications for where work should be focused. E.g., anti-depression smartphone apps developed in the US are unlikely to transfer well to India.
What is the actual effect size of CBT run “in the wild” via a scalable delivery mechanism like an app? How much of depression can we expect it to mitigate? Is the main problem to solve here finding a good intervention, or distributing it (i.e. getting people to use the CBT app or whatever)?
Have other (non-depression-related) interventions aimed directly at developed-world quality of life been tested? For instance, people notoriously neglect the effect of having a long daily commute on their happiness, and I suspect something similar applies to exercise and to food quality (at least, it does for me).
BTW, one note on the paper: you remark that “[a billionaire] should also run randomised controlled trials to assess how much happiness is increased by anti-poverty and anti-malarial interventions”—in fact, you can achieve a lower bound on the happiness increase of anti-malarial interventions because the main mechanism by which they reduce DALY burden (at least in GiveWell’s cost-effectiveness analysis) is by reducing mortality. Unlike severe pain, one cannot hedonically adapt to being dead, so anti-malarial interventions (and other mortality-reducing interventions) should have less of the 10x bias than e.g. cash transfers.
*I’m not incredibly confident in this argument; determining the actual quality of life burden here seems like a pretty subtle measurement problem of which I’d love to see a more thorough treatment than the paper provides, since it’s really the crux of the quantitative argument.
From what I can tell, the problem is more with outreach and retention than with effectiveness. Most of what I’ve read shows that computer based cognitive behavioral therapy (cCBT) is as effective as in-person CBT for anxiety and depression in the context of a RCT. But “in the wild”, rates of adherence drop considerably, with estimates of 0.5% and 1% completion in the only two published studies I could find [1,2].
If your server time and ongoing development costs are low enough, though, cCBT could still be a cost effective approach despite poor retention. This assumes that those that fail to complete the training aren’t harmed, but evidence seems to suggest that even partial completion is helpful [1,2]. Note that in study [1], about 15.6% completed 2 or more of the 5 modules, so a larger portion of people at least partially complete the training. I haven’t done a $/DALY estimate, but it would be fairly easy to come up with one with the results from study [1].
[1] A Comparison of Changes in Anxiety and Depression Symptoms of Spontaneous Users and Trial Participants of a Cognitive Behavior Therapy Website. http://www.jmir.org/2004/4/e46/
[2] Usage and Longitudinal Effectiveness of a Web-Based Self-Help Cognitive Behavioral Therapy Program for Panic Disorder. http://www.jmir.org/2005/1/e7/
Yes, but not formally. I’ll ask Howie if he’d like to comment on this post.
Hello Ben.
A couple of comments:
I wouldn’t expect people to be able to adapt to severe pain, not when you consider the evolutionary advantages of always taking your hand out of the fire. I’d expect people to die before they got used to pain.
What is going on is that mental pain may have a bigger impact on your happiness then physical pain and more than we imagine it does. I.e. chronic depression is worse than chronic lower back pain.
(You might reply that this is unfair because mental pain and happiness are basically the same thing: i.e. it’s obvious being unhappy has a bigger impact on happiness than just being in pain, so you’ve just measured the same thing twice. What you’d really want is data which showed the impact different health states have on people’s emotional experience/moods (which is what I take happiness to be). Nevertheless given that depression/anxiety seems to be lots of negative mental states, whereas chronic pain isn’t, that’s still a point in favour of depression/anxiety being where the unhappiness is.)
And yes, so I think depression, which already looks bad on DALYs, is much worse even than that.
Also, it seems that mental health issues are all over the world in a way that, say, malaria is quite concentrated. That’s why I say it’s possible mental health interventions may be more effective in developed rather than developing countries—people have more technology are greater familiar with mental health.
I can’t tell you what the ‘in the wild’ effect size is because I don’t know it and I don’t think it’s been tried. That’s why I suggest a billionaire tests it to find out! The evidence is the CBT works (remedies about 50% of cases of depression) so I’d say the challenge is more getting it to people and getting them to use it.
Developed world happiness interventions? I’m not sure what you mean. Some people in some governments are beginning to think explicitly in terms of happiness, but it hasn’t really caught on.
On the death thing, we have different intuitions. In your parlance, I’d say you adapt totally to being dead: there’s no you after death for anything to be good or bad for! So all this analysis is very sensitive to philosophical issues.
Sorry. Severe pain may have been a bad example. Other high-DALY-weight conditions do seem to show hedonic adaptation though, e.g. paraplegia (see my response to Lila for sources).
“hedonic adaptation applies to severe pain”
I find this implausible. Where’s the citation?
Sorry. Severe pain may have been a bad example. However, for instance, paraplegia does exhibit hedonic adaptation (source) despite having a disability weight of 0.57 (source).
A meta-analysis seems to contradict that (as well as claims in the OP): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289759/
Good find. Should have known better than to trust well-established pysch findings. (sob) Thanks for the correction, I’ll edit the OP.
I’m not sure what you think this meta-analysis contradicts. Could you please be more precise?
Card on the table, I’m more interested in ‘affective well-being’ than ‘cognitive well-being’ as they call it—i.e. ‘happiness’ rather than ’life satisfaction—and I take the meta-analysis as being broadly in my favour.