When you mention the $1000/DALY by “Stronger Minds,” are you referring to strongminds.org? I asked them if they had a cost estimate for DALYs but never received a reply. If it does refer to StrongMinds, do you know if they have predicted a cost per DALY once there viral group therapy model of treating depression grows significantly? Mayberry says in his TED talk that he expects it to become cheaper as it grows.
Also, does your discussion of DALYs for mental health interventions only include YLD, or also YLL? I would think there could be a large difference between the two considering the huge impact depression has on morbidity and mortality (comparable to obesity).
Are you saying you didn’t check footnote 45 of my paper? Outrageous! The $1000/DALY figure comes from
“Patel, V et al. (2015). Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities. The Lancet. These figures should be treated with caution. As the authors note, p1681 “hardly any published evidence exists on the cost-effectiveness of population-based or community-level strategies in or for low-income and middle-income settings” ”
I’m afraid I don’t know exactly who conducted the studies they refer to.
My criticism of MH intervention is more in terms of the way QALYs don’t seem to capture YLD in the same way a happiness-based approach would. I’m afraid I don’t, but probably should, know how Givewell’s $100 malaria figure is split between YLD and YLL and how the $1000 depression figure is split between YLD and YLL. I actually found it incredibly hard to find that sort of information, maybe because I’m a health economist and don’t know where to find it. If you know, please tell me!
In retrospect, I’m probably not careful enough in the paper and I’ll have to re-write it for the next draft. I say that QALYs underrate mental health by quite a bit, and on DALY estimates malaria is 10x cheaper, so maybe mental health treatments are in the right sort of ballpark already. Really I’d want to know how much depression and malaria each reduce happiness (‘happiness’ to be more carefully specified) whilst sufferers as still alive, and how much they increase mortality. Then you can do a more principled cost-effective analysis where you plug in how bad you think being dead is for someone. Unfortunately no one seems to be in the business of measuring health in terms of experienced happiness, so we may not be able to try and answer this question for some time.
Hi Michael! As I said before, congrats on an interesting paper.
A few points on this comment:
1) DCP3 didn’t have any cost-effectiveness figures for the StrongMinds intervention (interpersonal group therapy). Is the $1,000/DALY figure you mention related to primary care advice on alcohol use?
2) I’m currently writing a piece on mental health for a HNW donor and tried to model c-e of StrongMinds. I got c.$650/DALY reducing to $400/DALY as intervention scales. The biggest uncertainty in this estimate is the long term effects of psychosocial treatment as hardly any evidence exists. (I will post the calcs later—they’re on another computer)
1) check figure 3 on p1681 of DCP3. The box says “Depression: episodic treatment
in primary care with (generic) antidepressant medication and psychosocial treatment” at the box implies it’s between $1000/DALY and $10,000/DALY. I’m not sure exactly where those numbers came from. Have I misread that?
2) I’d be really keen to see your calculations and how you’re putting it all together!
3) Can you point out where in their spreadsheet they specify that? I’ve just spent 20 minutes looking through it and am a bit lost.
My estimate is then likely a miscalculation—thanks for pointing that out! What I should have done is use YLD figures for malaria and depression, and then transformed the disability rating using subjective well-being numbers.
Then I’d need to say something about the badness of losing a life. I think this indicates the perils of using DALY numbers…
1) Ah yes—thanks for pointing out. Probably has limited external validity for the strongminds model though (which is psychosocial treatment alone for most patients delivered by community health workers, with only the most serious cases referred to clinics for medication). The numbers come from the Chisholm (2015) WHO-CHOICE model. http://www.bmj.com/content/344/bmj.e609
[This is quick and dirty but gives a rough indication of cost-effectiveness. Most uncertain assumption is the long term impact of interpersonal group therapy on treated individuals 1-10 years down the line]
3) On the ‘bednets’ sheet you can see that the output measure is cost per under 5 child death averted. DALYs are then backcalculated from this to get c.$100 [not in sheet] . Something like $3,500 / 50 years of life for each death averted = c.$70/DALY. Because they’re only looking at deaths, it’s YLL not YLD. I haven’t seen a quantitative estimate of the total morbidity burden of malaria. One important consequence of surviving severe (cerebral) malaria is a much higher chance of getting epilepsy later in life http://www.ncbi.nlm.nih.gov/pubmed/25631856 although I suspect there are many others. Child health is really important!
Also—could you specify what you mean by mental health being 10-18 times worse than we think. Does this mean:
a) DALY weighting of severe depression is 0.65. Actually it should be 6.5 (so 6.5x worse than death. seems implausible)
or
b) Life with severe depression is worth 0.35 of healthy life. Actually it should be 0.035 (so 1 year of healthy life is worth c.30 years of life with severe depression. maybe but this seems like a lot)
Your comments to this blog post are very much appreciated—thank you for contributing.
We are a group of students at Oxford University doing a research project where we are trying to find the most effective charity to donate to (see https://oxpr.io/). We are currently looking into StrongMinds, and found your helpful cost-effectiveness model. If we may ask, we were wondering if possibly you have a more up-to-date / complete version of the same? And possibly also ask which inputs you received from StrongMinds vs. inputs estimated (and if so, how those estimates were made)?
Completely understandable if you don’t have time to answer all questions, but truly any feedback from you at all would be greatly appreciated.
1) Yeah, I never thought the numbers were that robust. More good measurement needed!
2) Thanks for this, will check this out soon.
3) Thanks
4). By being 10-18 times worse than we think, I mean anxiety/depression may cause about 10-18 more suffering than people expect them compared to other health conditions.
This is from the the Dolan and Metcalfe paper: they show people are prepared to trade off 15% of life to remove ‘some difficulty walking’ and ‘moderate anxiety or depression’, but that people with ‘moderate anxiety or depression’ report 10x the reduction in life satisfaction that those with ‘some difficulty walking’ do, and 18x reduction in terms of daily effect (their measure for what we might call ‘happiness’).
In other words, the average person imagines walking with a limp would be bad as moderate depression (as inferred from trade offs), but actually the depression would be much worse for their happiness than the limp. This is explained by the focusing illusion and the non-adaptation stuff.
If you look at the other numbers in the Dolan and Metcalfe paper, they show ‘self care’ and ‘usual activities’ are equally over-rated when people the trade-offs compared to how much they effect happiness.
In terms of weighting, my thought is that if we constructed well-being adjusted life years (WELBYs) depression would be 10-ish times worse than walking with a limb, but this would be rescaled. So if depression has a WELBY weight of 0.8 (e.g. 1 year with depression is worth 0.2 years of happy life), then minor mobility issues have a WELBY weight of 0.08 or something. I would not suggest all cases of mental health should be understood as being many times worse than death! I don’t think I implied that anyway, but I would clarify that in future.
The overall thought is more like: daily life with depression is quite bad in terms of happiness, health conditions which don’t cause depression (or pain) at all (or for very long) are probably not nearly as bad as we imagine they are, and we should re-prioritise bearing this in mind. Non-depression mental health disorders may also turn out to be much worse than we expect, and maybe also worse than most physical health conditions. This is all a bit broad (“what does ‘most physical health conditions mean?’”) but I hope you get the point.
When you mention the $1000/DALY by “Stronger Minds,” are you referring to strongminds.org? I asked them if they had a cost estimate for DALYs but never received a reply. If it does refer to StrongMinds, do you know if they have predicted a cost per DALY once there viral group therapy model of treating depression grows significantly? Mayberry says in his TED talk that he expects it to become cheaper as it grows.
Also, does your discussion of DALYs for mental health interventions only include YLD, or also YLL? I would think there could be a large difference between the two considering the huge impact depression has on morbidity and mortality (comparable to obesity).
Are you saying you didn’t check footnote 45 of my paper? Outrageous! The $1000/DALY figure comes from
“Patel, V et al. (2015). Addressing the burden of mental, neurological, and substance use disorders: key messages from Disease Control Priorities. The Lancet. These figures should be treated with caution. As the authors note, p1681 “hardly any published evidence exists on the cost-effectiveness of population-based or community-level strategies in or for low-income and middle-income settings” ”
I’m afraid I don’t know exactly who conducted the studies they refer to.
My criticism of MH intervention is more in terms of the way QALYs don’t seem to capture YLD in the same way a happiness-based approach would. I’m afraid I don’t, but probably should, know how Givewell’s $100 malaria figure is split between YLD and YLL and how the $1000 depression figure is split between YLD and YLL. I actually found it incredibly hard to find that sort of information, maybe because I’m a health economist and don’t know where to find it. If you know, please tell me!
In retrospect, I’m probably not careful enough in the paper and I’ll have to re-write it for the next draft. I say that QALYs underrate mental health by quite a bit, and on DALY estimates malaria is 10x cheaper, so maybe mental health treatments are in the right sort of ballpark already. Really I’d want to know how much depression and malaria each reduce happiness (‘happiness’ to be more carefully specified) whilst sufferers as still alive, and how much they increase mortality. Then you can do a more principled cost-effective analysis where you plug in how bad you think being dead is for someone. Unfortunately no one seems to be in the business of measuring health in terms of experienced happiness, so we may not be able to try and answer this question for some time.
Hi Michael! As I said before, congrats on an interesting paper.
A few points on this comment:
1) DCP3 didn’t have any cost-effectiveness figures for the StrongMinds intervention (interpersonal group therapy). Is the $1,000/DALY figure you mention related to primary care advice on alcohol use?
2) I’m currently writing a piece on mental health for a HNW donor and tried to model c-e of StrongMinds. I got c.$650/DALY reducing to $400/DALY as intervention scales. The biggest uncertainty in this estimate is the long term effects of psychosocial treatment as hardly any evidence exists. (I will post the calcs later—they’re on another computer)
3) Givewell’s estimate ignores YLD and is only based on U5 child mortality. So it’s entirely YLL. You can find the calculations here: http://www.givewell.org/international/technical/criteria/cost-effectiveness/cost-effectiveness-models
Hello James.
in reply:
1) check figure 3 on p1681 of DCP3. The box says “Depression: episodic treatment in primary care with (generic) antidepressant medication and psychosocial treatment” at the box implies it’s between $1000/DALY and $10,000/DALY. I’m not sure exactly where those numbers came from. Have I misread that?
2) I’d be really keen to see your calculations and how you’re putting it all together!
3) Can you point out where in their spreadsheet they specify that? I’ve just spent 20 minutes looking through it and am a bit lost.
My estimate is then likely a miscalculation—thanks for pointing that out! What I should have done is use YLD figures for malaria and depression, and then transformed the disability rating using subjective well-being numbers.
Then I’d need to say something about the badness of losing a life. I think this indicates the perils of using DALY numbers…
1) Ah yes—thanks for pointing out. Probably has limited external validity for the strongminds model though (which is psychosocial treatment alone for most patients delivered by community health workers, with only the most serious cases referred to clinics for medication). The numbers come from the Chisholm (2015) WHO-CHOICE model. http://www.bmj.com/content/344/bmj.e609
2) Analysis is here https://docs.google.com/spreadsheets/d/1-lCC1zQHVZlJS8f9OfqhzcZTetHMxuMkW7nT75QDGhk/edit#gid=960072536
[This is quick and dirty but gives a rough indication of cost-effectiveness. Most uncertain assumption is the long term impact of interpersonal group therapy on treated individuals 1-10 years down the line]
3) On the ‘bednets’ sheet you can see that the output measure is cost per under 5 child death averted. DALYs are then backcalculated from this to get c.$100 [not in sheet] . Something like $3,500 / 50 years of life for each death averted = c.$70/DALY. Because they’re only looking at deaths, it’s YLL not YLD. I haven’t seen a quantitative estimate of the total morbidity burden of malaria. One important consequence of surviving severe (cerebral) malaria is a much higher chance of getting epilepsy later in life http://www.ncbi.nlm.nih.gov/pubmed/25631856 although I suspect there are many others. Child health is really important!
Also—could you specify what you mean by mental health being 10-18 times worse than we think. Does this mean: a) DALY weighting of severe depression is 0.65. Actually it should be 6.5 (so 6.5x worse than death. seems implausible) or b) Life with severe depression is worth 0.35 of healthy life. Actually it should be 0.035 (so 1 year of healthy life is worth c.30 years of life with severe depression. maybe but this seems like a lot)
Hi James!
Your comments to this blog post are very much appreciated—thank you for contributing.
We are a group of students at Oxford University doing a research project where we are trying to find the most effective charity to donate to (see https://oxpr.io/). We are currently looking into StrongMinds, and found your helpful cost-effectiveness model. If we may ask, we were wondering if possibly you have a more up-to-date / complete version of the same? And possibly also ask which inputs you received from StrongMinds vs. inputs estimated (and if so, how those estimates were made)?
Completely understandable if you don’t have time to answer all questions, but truly any feedback from you at all would be greatly appreciated.
Please do let us know. Many many thanks!
1) Yeah, I never thought the numbers were that robust. More good measurement needed!
2) Thanks for this, will check this out soon.
3) Thanks
4). By being 10-18 times worse than we think, I mean anxiety/depression may cause about 10-18 more suffering than people expect them compared to other health conditions.
This is from the the Dolan and Metcalfe paper: they show people are prepared to trade off 15% of life to remove ‘some difficulty walking’ and ‘moderate anxiety or depression’, but that people with ‘moderate anxiety or depression’ report 10x the reduction in life satisfaction that those with ‘some difficulty walking’ do, and 18x reduction in terms of daily effect (their measure for what we might call ‘happiness’).
In other words, the average person imagines walking with a limp would be bad as moderate depression (as inferred from trade offs), but actually the depression would be much worse for their happiness than the limp. This is explained by the focusing illusion and the non-adaptation stuff.
If you look at the other numbers in the Dolan and Metcalfe paper, they show ‘self care’ and ‘usual activities’ are equally over-rated when people the trade-offs compared to how much they effect happiness.
In terms of weighting, my thought is that if we constructed well-being adjusted life years (WELBYs) depression would be 10-ish times worse than walking with a limb, but this would be rescaled. So if depression has a WELBY weight of 0.8 (e.g. 1 year with depression is worth 0.2 years of happy life), then minor mobility issues have a WELBY weight of 0.08 or something. I would not suggest all cases of mental health should be understood as being many times worse than death! I don’t think I implied that anyway, but I would clarify that in future.
The overall thought is more like: daily life with depression is quite bad in terms of happiness, health conditions which don’t cause depression (or pain) at all (or for very long) are probably not nearly as bad as we imagine they are, and we should re-prioritise bearing this in mind. Non-depression mental health disorders may also turn out to be much worse than we expect, and maybe also worse than most physical health conditions. This is all a bit broad (“what does ‘most physical health conditions mean?’”) but I hope you get the point.