The mental health EA cause space should explore more experimental, scalable interventions, such as promoting anti-inflammatory diets at school/college cafeterias to reduce depression in young people, or using lighting design to reduce seasonal depression. What I’ve seen of this cause area so far seems focused on psychotherapy in low-income countries. I feel like we’re missing some more out-of-the-box interventions here. Does anyone know of any relevant work along these lines?
There is still a lot of progress to be made in low-income country psychotherapy, which I think many EAs find counterintuitive. StrongMinds and Friendship Bench could both be about 5× cheaper, and have found ways to get substantially cheaper every year for the past half decade or so. At Kaya Guides, we’re exploring further improvements and should share more soon.
Plausibly, you could double cost-effectiveness again if it were possible to replace human counsellors with AI in a way that maintained retention (the jury is still out here).
The Happier Lives Institute has been looking at these kinds of interventions; their Promising Charities Pure Earth and Taimaka both appear to improve long-run mental health sustainably, by treating lead poisoning and malnutrition.
i think this is a good idea, but perhaps better excecutrd even by “non mental health” people. if your expertise is in psychotherapy why ditch that enormous competitive advantage?
i also think the evidence base on this stuff isn’t yet quite there? but I’m not up to date...
My gut feeling based on knowledge, reasoning, and experience is that the low-hanging fruit like diet and lighting is quite low-impact and probably has like low to middling cost-effectiveness — but I haven’t done any math, nor any experiments.
If I had research bucks to spend on experimental larks, I would try to push the psychotherapeutic frontier. For example, I might fund grounded theory research into depression. Or I might do a clinical trial on the efficacy of schema therapy for depression — there have been some promising results, but not many studies.
I think Johann Hari’s core point is correct — or at least a core point can be extracted from what he’s saying that is correct. Anti-depressants are very helpful for some people and moderately helpful for most people. Medical clinics that give ketamine to patients with treatment-resistant depression are helpful. Treatments that stimulate the brain with magnets and electricity are helpful. Neurofeedback may be helpful. But what all these approaches have in common is they’re trying to treat the brain like the engine in a car.
This kind of argument often gets mixed in with people who say that anti-depressants don’t work or are against them for some reason. Or people who advocate for non-evidence-based, woo woo “treatments”. But that’s not what I’m saying. Everyone who’s depressed should talk to a doctor about anti-depressants because the evidence for their efficacy is good and, even better, the side-effects for most people most of the time are fairly minor (providing they don’t mix them with the wrong drugs or substances), so the risk of trying them is low. And if one anti-depressant doesn’t work, the standard approach doctors will take is try 3-5 (over time, not all at once), to maximize the chance of one of them working. Other treatments like medical ketamine may be helpful or even life-changing for some people.
But I also think pharmacological and other biologistic approaches only take us so far. Depression is also about loneliness and social connection, and love and intimacy. It’s about trauma and personal history and upbringing. It’s about spiritual and existential questions, and how you find meaning in your life. I think a lot of therapists understand this, but the message isn’t getting across to a wider audience. In one of my favourite pieces of writing of all time, the personal essay “Ugly, Bitter, and True” by Suzanne Rivecca, the author recounts a conversation with her therapist:
There was something uniquely wrong with me, and I was sure of it. I told her my mental-health history: I’d been on SSRIs since I was 18; I hated psychiatrists, who I’d always found brusque and arrogant and reductive; I deeply resented my dependence on antidepressants and the genetic predisposition for major depression and anxiety, encoded in my DNA, that made it necessary to take them.
“Depression isn’t encoded in DNA,” she said.
“But almost everyone in my family has it,” I protested. “It’s a chemical imbalance, right?”
She said, “The brain changes chemically all the time. Trauma changes the brain. Stress changes the brain. Fear and love and connections change the brain. Intergenerational trauma and stress can correspond with intergenerational depression. Some of these responses are learned, not predetermined.”
She said this casually, as if she’d said it countless times to countless medicated Academy fellows bemoaning the tragic exceptionality of their innate neural shortcomings. She munched a cookie.
This probably wouldn’t have been an astounding revelation to most people. But it felt like one to me.
We’re confused about depression because we’re confused about consciousness. We can’t decide whether to treat the brain like a physical like, like a biological organ, or to treat the mind like a non-physical or spiritual or abstract thing. And we don’t know how to integrate these perspectives or to appropriately switch between them. We’ve got (in the terminology of the philosopher Wilfred Sellars) the manifest images of phenomenology (first-person subjective experience) on the one hand, and the scientific image of the brain on the other hand. What do we do with them? We’re not quite sure.
I always notice how people note with apparent surprise that some thing that clearly has an effect on our minds has an effect on our brains, according to some new scientific study. Unless we believe in dualism — if we believe in physicalism — this shouldn’t come as a surprise, since everything that happens in the mind must happen in the brain. If there’s any surprise, it’s only that the effect is detectable with our current knowledge and instruments. Literally everything changes your brain. This sentence is changing your brain in a micro way. If it wasn’t, either you wouldn’t be reading it or you would have an immaterial soul.
I have more optimism, or at least more curiosity, about psychotherapeutic research and innovation than about experimenting more with biologistic approaches. They’re not mutually exclusive, at all, that’s just where my hope/interest is strongest. Depression is a hard problem, and to make meaningful progress, we probably have to wrangle with the hard stuff: love, meaning, trust, trauma, upbringings, the spiritual and existential. Qualitative methodologies in the social sciences seem better-equipped to explore this stuff. We really should try to develop and test more psychotherapeutic methodologies than cognitive behavioural therapy (CBT). CBT is not really equipped to deal with the hard stuff.
For instance, in CBT there is a strong undercurrent of telling you that your anxious or negative thoughts are irrational and pointing out patterns like black-and-white thinking or catastrophizing. That’s fine as far as it goes, but it doesn’t go far. I have come to believe it’s more constructive to figure out the perspective from which your (seemingly) irrational thoughts are rational than to dismiss them as irrational. There is probably a rational reason why you learned to think that your friends might secretly dislike you. It might have been something you learned from experience way in the past. The blanket dismissals of CBT don’t provide the reassurance the soul needs. They don’t provide a healing experience from which a new pattern can be learned. Alternative schools of thought like schema therapy explicitly focus on that. The clinical trial results so far are promising.
The mental health EA cause space should explore more experimental, scalable interventions, such as promoting anti-inflammatory diets at school/college cafeterias to reduce depression in young people, or using lighting design to reduce seasonal depression. What I’ve seen of this cause area so far seems focused on psychotherapy in low-income countries. I feel like we’re missing some more out-of-the-box interventions here. Does anyone know of any relevant work along these lines?
A few points:
There is still a lot of progress to be made in low-income country psychotherapy, which I think many EAs find counterintuitive. StrongMinds and Friendship Bench could both be about 5× cheaper, and have found ways to get substantially cheaper every year for the past half decade or so. At Kaya Guides, we’re exploring further improvements and should share more soon.
Plausibly, you could double cost-effectiveness again if it were possible to replace human counsellors with AI in a way that maintained retention (the jury is still out here).
The Happier Lives Institute has been looking at these kinds of interventions; their Promising Charities Pure Earth and Taimaka both appear to improve long-run mental health sustainably, by treating lead poisoning and malnutrition.
i think this is a good idea, but perhaps better excecutrd even by “non mental health” people. if your expertise is in psychotherapy why ditch that enormous competitive advantage?
i also think the evidence base on this stuff isn’t yet quite there? but I’m not up to date...
My gut feeling based on knowledge, reasoning, and experience is that the low-hanging fruit like diet and lighting is quite low-impact and probably has like low to middling cost-effectiveness — but I haven’t done any math, nor any experiments.
If I had research bucks to spend on experimental larks, I would try to push the psychotherapeutic frontier. For example, I might fund grounded theory research into depression. Or I might do a clinical trial on the efficacy of schema therapy for depression — there have been some promising results, but not many studies.
I think Johann Hari’s core point is correct — or at least a core point can be extracted from what he’s saying that is correct. Anti-depressants are very helpful for some people and moderately helpful for most people. Medical clinics that give ketamine to patients with treatment-resistant depression are helpful. Treatments that stimulate the brain with magnets and electricity are helpful. Neurofeedback may be helpful. But what all these approaches have in common is they’re trying to treat the brain like the engine in a car.
This kind of argument often gets mixed in with people who say that anti-depressants don’t work or are against them for some reason. Or people who advocate for non-evidence-based, woo woo “treatments”. But that’s not what I’m saying. Everyone who’s depressed should talk to a doctor about anti-depressants because the evidence for their efficacy is good and, even better, the side-effects for most people most of the time are fairly minor (providing they don’t mix them with the wrong drugs or substances), so the risk of trying them is low. And if one anti-depressant doesn’t work, the standard approach doctors will take is try 3-5 (over time, not all at once), to maximize the chance of one of them working. Other treatments like medical ketamine may be helpful or even life-changing for some people.
But I also think pharmacological and other biologistic approaches only take us so far. Depression is also about loneliness and social connection, and love and intimacy. It’s about trauma and personal history and upbringing. It’s about spiritual and existential questions, and how you find meaning in your life. I think a lot of therapists understand this, but the message isn’t getting across to a wider audience. In one of my favourite pieces of writing of all time, the personal essay “Ugly, Bitter, and True” by Suzanne Rivecca, the author recounts a conversation with her therapist:
We’re confused about depression because we’re confused about consciousness. We can’t decide whether to treat the brain like a physical like, like a biological organ, or to treat the mind like a non-physical or spiritual or abstract thing. And we don’t know how to integrate these perspectives or to appropriately switch between them. We’ve got (in the terminology of the philosopher Wilfred Sellars) the manifest images of phenomenology (first-person subjective experience) on the one hand, and the scientific image of the brain on the other hand. What do we do with them? We’re not quite sure.
I always notice how people note with apparent surprise that some thing that clearly has an effect on our minds has an effect on our brains, according to some new scientific study. Unless we believe in dualism — if we believe in physicalism — this shouldn’t come as a surprise, since everything that happens in the mind must happen in the brain. If there’s any surprise, it’s only that the effect is detectable with our current knowledge and instruments. Literally everything changes your brain. This sentence is changing your brain in a micro way. If it wasn’t, either you wouldn’t be reading it or you would have an immaterial soul.
I have more optimism, or at least more curiosity, about psychotherapeutic research and innovation than about experimenting more with biologistic approaches. They’re not mutually exclusive, at all, that’s just where my hope/interest is strongest. Depression is a hard problem, and to make meaningful progress, we probably have to wrangle with the hard stuff: love, meaning, trust, trauma, upbringings, the spiritual and existential. Qualitative methodologies in the social sciences seem better-equipped to explore this stuff. We really should try to develop and test more psychotherapeutic methodologies than cognitive behavioural therapy (CBT). CBT is not really equipped to deal with the hard stuff.
For instance, in CBT there is a strong undercurrent of telling you that your anxious or negative thoughts are irrational and pointing out patterns like black-and-white thinking or catastrophizing. That’s fine as far as it goes, but it doesn’t go far. I have come to believe it’s more constructive to figure out the perspective from which your (seemingly) irrational thoughts are rational than to dismiss them as irrational. There is probably a rational reason why you learned to think that your friends might secretly dislike you. It might have been something you learned from experience way in the past. The blanket dismissals of CBT don’t provide the reassurance the soul needs. They don’t provide a healing experience from which a new pattern can be learned. Alternative schools of thought like schema therapy explicitly focus on that. The clinical trial results so far are promising.