Cost Effectiveness of Mindfulness Based Stress Reduction

The Problem

The WHO es­ti­mates that de­pres­sion and anx­iety to­gether ac­count for 75,000,000 DALYs an­nu­ally, mak­ing up ~5% of to­tal DALYs. In “Mea­sur­ing the Im­pact of Men­tal Ill­ness on Qual­ity of Life”, I ar­gue that there is good rea­son to think that the sys­tem used to gen­er­ate these es­ti­mates severely un­der­es­ti­mates the im­pact of men­tal ill­ness, and thus the true dam­age may be much higher. To try to get an es­ti­mate on the harms of men­tal health and the benefits of alievi­at­ing men­tal health prob­lems, I did a pre­limi­nary cost-effec­tive­ness anal­y­sis of Mind­ful­ness Based Stress Re­duc­tion (MBSR).

The Intervention

MBSR is an eight week class that uses a com­bi­na­tion of mind­ful­ness, body aware­ness, and yoga to im­prove qual­ity of life and per­haps phys­i­cal health for a va­ri­ety of con­di­tions.

MBSR was cre­ated by Jon Ka­bat-Zinn at the Univer­sity of Mas­sachusetts in the 1970s, but has spread widely since then. The ex­act ex­tent of this spread is hard to mea­sure be­cause no offi­cial reg­is­tra­tion is re­quired to teach mind­ful­ness and many classes and books claim to be mind­ful­ness in­spired. For the pur­pose of this eval­u­a­tion I looked only at things that were offi­cially MBSR or ad­hered very closely to the de­scrip­tion.

Cost of MBSR

Her­man, et al. (2017) es­ti­mated the marginal cost of an MBSR class par­ti­ci­pant at $150. The first three hits on google (run in an incog­nito browser but sus­pi­ciously near the lo­ca­tion from which I ran the search) for MBSR listed a cost of $395-$595, $275-$425, and $350. The differ­ence be­tween the top of the range and the marginal cost in­di­cates that the high end of that range prob­a­bly cov­ers all of the costs in­volved with MBSR (space rental and in­struc­tor time for eight weeks of classes plus one eight hour re­treat) and then some, so I will use $600 as the ceiling on costs and $150 as the floor.

MBSR has an un­usu­ally high time on­go­ing cost (one hour per day). To model this, I in­cluded a range of DALYs as a cost, rang­ing from 0 (in­di­cat­ing no cost) to 124 (as if the par­ti­ci­pant were dead for that hour). It is un­clear how the one hour du­ra­tion was cho­sen and I could not find any stud­ies on the com­par­a­tive im­pact of differ­ent lengths of med­i­ta­tion; it’s quite plau­si­ble one could get the same re­sults in less time. For the pur­pose of this doc­u­ment I used the offi­cial pro­gram, be­cause it was the most con­sis­tently stud­ied.

Cost Effec­tive­ness Anal­y­sis of MBSR

Both de­pres­sion and anx­iety are mea­sured with a va­ri­ety of clini­cal sur­veys. To es­ti­mate im­pact, I as­sumed that the top score on each sur­vey caused a DALY loss equal to se­vere de­pres­sion/​anx­iety, as es­ti­mated by the World Health Or­ga­ni­za­tion, and that a drop of N per­centage points led to a drop of dis­abil­ity weight * N. For ex­am­ple, a drop of 8 points on an 80 point scale of anx­iety (dis­abil­ity weight of se­vere anx­iety: 0.523) causes a gain of .0523 DALYs.

For a sur­vey of pa­pers show­ing po­ten­tial im­pact, see this spread­sheet. The es­ti­mates range from 2% to 11%, clus­tered around 7%.

I have cre­ated a Guessti­mate model to es­ti­mate the im­pact of MBSR. Re­sults were quite promis­ing. On a ran­domly se­lected guessti­mate run, the av­er­age cost was $290/​DALY, with a range from $43/​DALY to $930/​DALY. This is close to but bet­ter than Strong Mind’s $650/​DALY and over­laps with es­ti­mates of an­ti­malar­ial treat­ment ($8.15-$150/​DALY). Note that the MBSR es­ti­mate may un­der­state the im­pact due to sys­temic bi­ases in how DALYs are calcu­lated. How­ever it may also over­state the im­pact, as med­i­cal stud­ies tend to over­state in­ter­ven­tion im­pacts for a va­ri­ety of rea­sons.

The model makes no at­tempt to ac­count for co-mor­bid di­s­or­ders. In­di­vi­d­u­als with de­pres­sion and anx­iety would likely see higher benefits, since the same hour of med­i­ta­tion would im­pact both.

This model makes the rather op­ti­mistic as­sump­tion the benefits per­sist for life. This as­sumes that the par­ti­ci­pant would have been coun­ter­fac­tu­ally de­pressed for­ever with­out treat­ment. In re­al­ity the av­er­age de­pres­sive epi­sode lasts six months, and of peo­ple who have suffered at least one epi­sode, the av­er­age life­time num­ber of epi­sodes is four. If we as­sume the par­ti­ci­pant gets two years of benefit out of treat­ment the cost be­comes $1200 to $14,000/​DALY, with an av­er­age of $5200/​DALY.

Caveats

All of the effec­tive­ness stud­ies cited were done on de­vel­oped world cit­i­zens with only mild to mod­er­ate men­tal ill­nesses. Most were mid­dle aged, and ac­cess to MBSR im­plies a min­i­mum SES bar. It is pos­si­ble that more se­vere de­pres­sion is not amenable to MBSR, or that it is amenable and shows a larger ab­solute change be­cause there is farther to im­prove.

I could find no stud­ies on MBSR in the de­vel­op­ing world, al­though since mind­ful­ness med­i­ta­tion was origi­nally cre­ated be­fore there was such a thing as the de­vel­oped world, there is a higher than typ­i­cal chance that its use­ful­ness will sur­vive cul­tural trans­la­tion.

All of the stud­ies refer­enced had small sam­ple sizes. They all show a con­sis­tent effect, but it’s pos­si­ble pub­li­ca­tion bias is keep­ing nega­tive stud­ies out of view.

Offi­cial MBSR has an un­usu­ally high time cost com­pared to med­i­ca­tion and ther­apy. The costs are high both up­front (eight weeks of classes and an all day re­treat) and on­go­ing (one hour of med­i­ta­tion/​day). Some pa­tients may be able to get the benefits of MBSR with less time; oth­ers may not be able to prac­tice at all due to the time de­mands.