G’day Madeline, I run an EA mental health org in India. The reason for this is simply that existing mental health interventions do not compare with GiveWell’s grants on a DALYs/$ basis. In my opinion, the reasons are:
DALY moral weights may be biased against depression
The moral weights of different diseases in the Global Burden of Disease study, which informs DALY estimates, are determined by asking the general public whether they’d prefer to have one disease against another. When you do this with depression, people who haven’t experienced it tend to prefer to have it to many other conditions. However, when you ask people who have experienced it, they choose many very painful conditions over depression. This is one of the widest gaps in the moral weight data. See Pyne et al. 2009 and this post.
Psychotherapy is usually modelled as a short-term effect
Psychotherapy is typically modelled as a treatment, and not a ‘skill’. What I mean by this is that a dose of psychotherapy is assumed to only have effects that decay over a period of time and zero out after that in most CEAs, including those from the Happier Lives Institute. However, many psychotherapy patients will tell you that they learned skills that were useful long after the therapy ended, and there is some limited evidence that psychotherapy’s effects may last decades, or potentially never zero out. If this were true, the effects could be very long-lasting and therefore it would be much more valuable to treat a case of depression.
Suicide prevention isn’t cost-effective if it’s only a short-term effect
Consider that for most of GiveWell’s top interventions, the bulk of the DALYs averted come from ‘saving’ a life—i.e., preventing a death from a disease in a way that allows the person to then go on to live a healthy life, such as preventing a malaria case in an under-5 (which they might die from), even if they go on to catch it after 5 years old.
As a short-term effect, psychotherapy can only postpone a suicide by the length of the treatment effect. But if it were a skill and had some durable long-term effect, it may genuinely prevent one, which would tremendously increase the value of suicide prevention interventions.
Existing interventions haven’t been cheap enough yet
With the exception of some incredible policy work in, for example, reducing toxicity of pesticides commonly used for suicide, existing interventions are still quite expensive. The Happier Lives Institute’s top charities cost ~$40 to treat a single person, while a bednet costs $7. I’m fudging the numbers a bit here, but if we stick with DALYs, psychotherapy is still about an order of magnitude more expensive than it needs to be to look great for EAs.
However, there is work being done to improve that! My charity, Kaya Guides, treated people for $20 each in April, at what we estimate is a similar effect size to the best charities, and we’re confident we can get below $10. We’re using a technique called guided self-help that allows us to dramatically reduce contact hours per participant (and being all-digital helps a lot, too).
Conclusion
Orgs like the Happier Lives Institute have done a lot of advocacy work too, to raise the profile of mental health within EA, and there are plenty of funders that take mental health seriously (in a way that apparently wasn’t true a decade ago). It is, after all, still a nascent space.
Thanks for mentioning our work in HLI here @huw. I/we are not so active on the forum these days, so you beat us to it.
But yes, @madeleine_foley, HLI really got started, now 7 years ago, because we thought that the standard economist approach of focusing on just health and wealth was not going a good job of capturing what people’s lives are like on the inside. We’ve been pioneering wellbeing cost-effectiveness analysis and a metric called WELLBYs (wellbeing years) to see what the priorities are if you ‘take happiness seriously’. (Oddly, we were the first team to do wellbeing ROI, but now quite a few others, including the UK and NZ Treasuries, use the same method, although not because of us). We concluded that mental health is a neglected priority, and have been recommended charities working on it for the last few years, and advocating for it more broadly. Huw’s organisation, Kaya Guides, is one we’re very excited about, and he’s right that global human happiness and mental health is an emergent part of the wider cause area of ‘global health and wellbeing’, and just wasn’t part of the conversation in effective altruism before.
Thank you @huw and apologies for my delay- still getting the hang of the forum! I really appreciate these insights and would love to learn more about the work you are doing at Kaya Guides. I have been thinking a lot about what innovation would look like in the mental health space and how the personal nature of mental health makes widespread interventions challenging (for example, medication can not necessarily cure mental illness the way it can cure a physical ailment like an infection).
G’day Madeline, I run an EA mental health org in India. The reason for this is simply that existing mental health interventions do not compare with GiveWell’s grants on a DALYs/$ basis. In my opinion, the reasons are:
DALY moral weights may be biased against depression
The moral weights of different diseases in the Global Burden of Disease study, which informs DALY estimates, are determined by asking the general public whether they’d prefer to have one disease against another. When you do this with depression, people who haven’t experienced it tend to prefer to have it to many other conditions. However, when you ask people who have experienced it, they choose many very painful conditions over depression. This is one of the widest gaps in the moral weight data. See Pyne et al. 2009 and this post.
Psychotherapy is usually modelled as a short-term effect
Psychotherapy is typically modelled as a treatment, and not a ‘skill’. What I mean by this is that a dose of psychotherapy is assumed to only have effects that decay over a period of time and zero out after that in most CEAs, including those from the Happier Lives Institute. However, many psychotherapy patients will tell you that they learned skills that were useful long after the therapy ended, and there is some limited evidence that psychotherapy’s effects may last decades, or potentially never zero out. If this were true, the effects could be very long-lasting and therefore it would be much more valuable to treat a case of depression.
Suicide prevention isn’t cost-effective if it’s only a short-term effect
Consider that for most of GiveWell’s top interventions, the bulk of the DALYs averted come from ‘saving’ a life—i.e., preventing a death from a disease in a way that allows the person to then go on to live a healthy life, such as preventing a malaria case in an under-5 (which they might die from), even if they go on to catch it after 5 years old.
As a short-term effect, psychotherapy can only postpone a suicide by the length of the treatment effect. But if it were a skill and had some durable long-term effect, it may genuinely prevent one, which would tremendously increase the value of suicide prevention interventions.
Existing interventions haven’t been cheap enough yet
With the exception of some incredible policy work in, for example, reducing toxicity of pesticides commonly used for suicide, existing interventions are still quite expensive. The Happier Lives Institute’s top charities cost ~$40 to treat a single person, while a bednet costs $7. I’m fudging the numbers a bit here, but if we stick with DALYs, psychotherapy is still about an order of magnitude more expensive than it needs to be to look great for EAs.
However, there is work being done to improve that! My charity, Kaya Guides, treated people for $20 each in April, at what we estimate is a similar effect size to the best charities, and we’re confident we can get below $10. We’re using a technique called guided self-help that allows us to dramatically reduce contact hours per participant (and being all-digital helps a lot, too).
Conclusion
Orgs like the Happier Lives Institute have done a lot of advocacy work too, to raise the profile of mental health within EA, and there are plenty of funders that take mental health seriously (in a way that apparently wasn’t true a decade ago). It is, after all, still a nascent space.
Thanks for mentioning our work in HLI here @huw. I/we are not so active on the forum these days, so you beat us to it.
But yes, @madeleine_foley, HLI really got started, now 7 years ago, because we thought that the standard economist approach of focusing on just health and wealth was not going a good job of capturing what people’s lives are like on the inside. We’ve been pioneering wellbeing cost-effectiveness analysis and a metric called WELLBYs (wellbeing years) to see what the priorities are if you ‘take happiness seriously’. (Oddly, we were the first team to do wellbeing ROI, but now quite a few others, including the UK and NZ Treasuries, use the same method, although not because of us). We concluded that mental health is a neglected priority, and have been recommended charities working on it for the last few years, and advocating for it more broadly. Huw’s organisation, Kaya Guides, is one we’re very excited about, and he’s right that global human happiness and mental health is an emergent part of the wider cause area of ‘global health and wellbeing’, and just wasn’t part of the conversation in effective altruism before.
Thank you @huw and apologies for my delay- still getting the hang of the forum! I really appreciate these insights and would love to learn more about the work you are doing at Kaya Guides. I have been thinking a lot about what innovation would look like in the mental health space and how the personal nature of mental health makes widespread interventions challenging (for example, medication can not necessarily cure mental illness the way it can cure a physical ailment like an infection).