A quick response—I’ll respond in more depth later,
I love the idea of your RCT cash transfers vs. psychotherapy but I’m confused about a number of parts of the design and have a few questions if you will humour me .
To be clear, the planned RCT has nothing to do with HLI, so I would forward all questions to the authors! :)
And to be clear when you say “before and after measures”, do you think this applies to RCTs where the measurement of an effect is comparing a control to a treatment group instead of before and after a group receives an intervention?
Apologies for assuming that the RCT involved HLI—the strong minds involvement lead me to that wrong assumption! They will then be addressing different questions than we are here—unfortunately for us that trial as stated in the protocol doesn’t test cash transfers vs. psychotherapy.
I don’t quite understand the distinction in your question sorry, will need rephrasing! I’m referencing the problems with any SWB measurement which involves measuring SWB at baseline and then after an intervention. Whether there is a control arm or not.
Right, our concern is that if this bias exists, it is stronger for one intervention than another. E.g., say psychotherapy is more susceptible than cash transfers. If the bias is balanced across both interventions, then again, not as much of an issue.
I’m wondering if this bias your concerned with would be captured by a “placebo” arm of an RCT. Imagine a control group that receives an intervention that we think has no to little effect. If you expect any intervention to activate this “future hope” bias, then we could potentially estimate the extent of this bias with more trials including three arms: a placebo, a receive nothing, and an intervention arm.
Do you have any ideas on how to elicit this bias experimentally? Could we instruct interviewers to, for a subsample of the people in a trial, explicit something like “any future assistance [ will / will not] depend on the benefit this intervention provided.” Anything verbal like this would be cheapest to test.
”Right, our concern is that if this bias exists, it is stronger for one intervention than another. E.g., say psychotherapy is more susceptible than cash transfers. If the bias is balanced across both interventions, then again, not as much of an issue.”
I would have thought the major concern would have been if the bias existed at all, rather than whether it balanced between interventions. Both StrongMinds evidence assessing their own program and most of the studies used in your WELLBY analysis are NOT vs. another intervention, but rather Psychotherapy vs. No intervention. This is often labelled “Normal care”, which is usually nothing in low income countries. So if it exists at all in any magnitude, it will be affecting your results.
Onto your question though, which is still important but I believe of secondary importance
Your idea of a kind of “fake” placebo arm would work—providing the fake placebo was hyped up as much and taken as seriously as the treatment arm, AND that the study participants really didn’t know it was a placebo. Unfortunately you can’t do this as It’s not ethical to have an RCT with an intervention that you think has no or little effect. So not possible I don’t think
I like your idea of interviewers in a trial stating for a subset of people that their answers won’t change whether they get more or not n future. I doubt this would mitgate the effect much or at all, but it’s a good idea to try!
My very strong instinct is that cash transfers would illicit a FAR stronger effect than psychotherapy. It’s hard to imagine anything that would illicit “future hope” more than the possibility of getting cash in future. This seems almost self-evident. Which extremely poor person in their right mind (whether their mental health really is better or not) is going to say that cash didn’t help their mental health if they think it might increase their chance of getting more cash in future?
Again I think just direct RCTs vs. Cash Transfers is the best way to test your intervention and control for this bias. It’s hard to imagine anything having a larger “future hope” effect than cash. If psychotherapy really beat the cash given that cash will almost certainly have a bigger “future hope” bias than the psychotherapy, then I’d say you’d have a slam dunk case.
I am a bit bewildered that StrongMinds has never done a psychotherapy vs. Cash transfer trial. This is the big question, and you claim that Strongminds therapy produces more WELLBYs than Cash Transfers yet there is no RCT?It looks like that trial you sent me is another painful missed opportunity to do that research as well. Why there is no straight cash transfer arm in that trial doesn’t make any sense.
As far as I can see the Kenyan trial is the only RCT with Subjective wellness assessment which pits Cash Transfers vs. Psychotherapy (although it was a disproportionately large cash transfer and not the Strongminds style group therapy). If group Psychotherapy beat an equivalent cash Cash transfer in say 2 RCTs I might give up my job and start running group psychotherapy sessions—that would be powerful!
Hi Nick. I found more details about the Baird et al. RCT here. I’ve copied the section about the ‘cash alone’ arm below as I know you’ll be interested to read that:
One of the issues that can cause difficulties in the interpretation of the findings from this study comes from the fact that it does not have a classical 2x2 factorial design that includes a “cash alone” arm. While it would have been ideal, from a study design perspective, to have such a design, which would have enabled us to experimentally reject (or not) that cash alone would have been as effective as IPT-G+. Such benchmarking of the (cost-) effectiveness of a group therapy intervention to cash transfers alone would have been nice, the three-arm trial we designed for our setting, leaving out a “cash-only” arm, is an adequate study design for the following three reasons.
First, the extant evidence on the effects of economic interventions in general, or cash transfers in particular, do not support the idea of improved mental health outcomes past the short-run. For example, in their review, Lund et al. (2011) finds that the mental health effects of poverty alleviation programs were inconclusive. Blattman, Jamison, and Sheridan (2017) find no effects of lump-sum cash transfers alone on mental health outcomes in the short- or the medium-run. Short-term effects of cash transfers (monthly or lump-sum) on psychological wellbeing that were observed in the short-run dissipated a couple of years later (Baird, de Hoop, and Özler 2013; Baird, McIntosh and Özler 2019; Haushofer and Shapiro 2016, 2018). Hence, we do not think that there is sufficient equipoise to include a “cash only” arm when it comes to sustained effects on depression two-years after the end of the intervention.
Second, even if one could make a case that there may be a sustained income effect on mental health – for example, such as those indicated by studies of lottery winners (Gardner and Oswald 2007; Lindahl 2005) – the amounts offered to IPT-G participants here are too small to have this kind of an effect two years after they are transferred. A similar argument has been made in another experiment that lacked a pure unconditional cash transfer (UCT) arm: Benhassine et al. (2015) argue that the labelling of the cash transfer as an education support program increased school participation through its effect on the “...parents’ belief that education was a worthwhile investment,” rather than through a pure income effect, because the transfers were too small to cause the observed effects.
Finally, and related to the point above, one of the aims of our trial is to test the efficacy of a low-cost and scalable intervention through two NGOs that have a track record of implementing programs that are being utilized here (BRAC Uganda and StrongMinds Uganda). While BRAC Uganda is interested in taking advantage of its ELA girls’ clubs’ platform to provide mental health services across Uganda, it does not have any plans to provide UCTs, especially not in transfer sizes that might perhaps have sustained effects. Hence, the lack of evidence on the potential effectiveness of UCTs on sustained reductions in depression, combined with a lack of interest from the implementing partners, resulted in the study team designing a trial that has only three arms. Should the trial show that IPT-G+ is significantly more effective than IPT-G alone in reducing depression in the medium-run, our interpretation will be that there is a complementarity between the two interventions, and not that cash is effective on its own for sustained improvements in psychological wellbeing.
Thanks Barry I tried to find this earlier but couldn’t.
I find these arguments rather uncompelling. What do you think Barry and Joel? (I wish I could tag people on this forum haha)
That they feel the need to write 4 paragraphs to defend against this elephant in the room says a lot. The question we are all still asking is how much better (if at all) StrongMinds really is than cash for wellbeing.
My first question is why don’t they reference the 2020 Haushofer study, the only RCT comparing psychotherapy to cash and showing cash is better? https://www.nber.org/papers/w28106
Second, their equipoise argument is very poor. The control arm should have been BRAC ELA club + cash. Then you keep 3 arms and avoid their straw man 4 arm problem. You would lose nothing in equipoise giving cash to the control arm—I don’t understand the equipoise argument perhaps I’m missing something?
Then third there’s this...
“Should the trial show that IPT-G+ is significantly more effective than IPT-G alone in reducing depression in the medium-run, our interpretation will be that there is a complementarity between the two interventions, and not that cash is effective on its own for sustained improvements in psychological wellbeing.”
This is the most telling paragraph. It’s like, we designed our study so that even if we see that cash gives a big boost, we aren’t going to consider the alternative that we don’t like. It seems to me like they are defending poor design post-hoc, rather than that they made good decision made in advance.
The more I see this, the more I suspect that leaving the cash arm out was either a big mistake or an intentional move by the NGOs. What we have now is a million dollar RCT, which doesn’t answer conclusively the most important question we are all asking. This leaves organisations like your HLI having to use substandard data to assess psychotherapy vs. cash because there is no direct gold standard comparison.
It’s pretty sad that a million dollars will be spent on a study that at best fails to address the elephant in the room (while spending 4 paragraphs explaining why they are not). Other than that the design and reasoning in this study seems fantastic.
A quick response—I’ll respond in more depth later,
To be clear, the planned RCT has nothing to do with HLI, so I would forward all questions to the authors! :)
And to be clear when you say “before and after measures”, do you think this applies to RCTs where the measurement of an effect is comparing a control to a treatment group instead of before and after a group receives an intervention?
Apologies for assuming that the RCT involved HLI—the strong minds involvement lead me to that wrong assumption! They will then be addressing different questions than we are here—unfortunately for us that trial as stated in the protocol doesn’t test cash transfers vs. psychotherapy.
I don’t quite understand the distinction in your question sorry, will need rephrasing! I’m referencing the problems with any SWB measurement which involves measuring SWB at baseline and then after an intervention. Whether there is a control arm or not.
Looking forward to hearing more nice one!
Right, our concern is that if this bias exists, it is stronger for one intervention than another. E.g., say psychotherapy is more susceptible than cash transfers. If the bias is balanced across both interventions, then again, not as much of an issue.
I’m wondering if this bias your concerned with would be captured by a “placebo” arm of an RCT. Imagine a control group that receives an intervention that we think has no to little effect. If you expect any intervention to activate this “future hope” bias, then we could potentially estimate the extent of this bias with more trials including three arms: a placebo, a receive nothing, and an intervention arm.
Do you have any ideas on how to elicit this bias experimentally? Could we instruct interviewers to, for a subsample of the people in a trial, explicit something like “any future assistance [ will / will not] depend on the benefit this intervention provided.” Anything verbal like this would be cheapest to test.
Hi Joel—Nice one again
”Right, our concern is that if this bias exists, it is stronger for one intervention than another. E.g., say psychotherapy is more susceptible than cash transfers. If the bias is balanced across both interventions, then again, not as much of an issue.”
I would have thought the major concern would have been if the bias existed at all, rather than whether it balanced between interventions. Both StrongMinds evidence assessing their own program and most of the studies used in your WELLBY analysis are NOT vs. another intervention, but rather Psychotherapy vs. No intervention. This is often labelled “Normal care”, which is usually nothing in low income countries. So if it exists at all in any magnitude, it will be affecting your results.
Onto your question though, which is still important but I believe of secondary importance
Your idea of a kind of “fake” placebo arm would work—providing the fake placebo was hyped up as much and taken as seriously as the treatment arm, AND that the study participants really didn’t know it was a placebo. Unfortunately you can’t do this as It’s not ethical to have an RCT with an intervention that you think has no or little effect. So not possible I don’t think
I like your idea of interviewers in a trial stating for a subset of people that their answers won’t change whether they get more or not n future. I doubt this would mitgate the effect much or at all, but it’s a good idea to try!
My very strong instinct is that cash transfers would illicit a FAR stronger effect than psychotherapy. It’s hard to imagine anything that would illicit “future hope” more than the possibility of getting cash in future. This seems almost self-evident. Which extremely poor person in their right mind (whether their mental health really is better or not) is going to say that cash didn’t help their mental health if they think it might increase their chance of getting more cash in future?
Again I think just direct RCTs vs. Cash Transfers is the best way to test your intervention and control for this bias. It’s hard to imagine anything having a larger “future hope” effect than cash. If psychotherapy really beat the cash given that cash will almost certainly have a bigger “future hope” bias than the psychotherapy, then I’d say you’d have a slam dunk case.
I am a bit bewildered that StrongMinds has never done a psychotherapy vs. Cash transfer trial. This is the big question, and you claim that Strongminds therapy produces more WELLBYs than Cash Transfers yet there is no RCT? It looks like that trial you sent me is another painful missed opportunity to do that research as well. Why there is no straight cash transfer arm in that trial doesn’t make any sense.
As far as I can see the Kenyan trial is the only RCT with Subjective wellness assessment which pits Cash Transfers vs. Psychotherapy (although it was a disproportionately large cash transfer and not the Strongminds style group therapy). If group Psychotherapy beat an equivalent cash Cash transfer in say 2 RCTs I might give up my job and start running group psychotherapy sessions—that would be powerful!
Hi Nick. I found more details about the Baird et al. RCT here. I’ve copied the section about the ‘cash alone’ arm below as I know you’ll be interested to read that:
Thanks Barry I tried to find this earlier but couldn’t.
I find these arguments rather uncompelling. What do you think Barry and Joel? (I wish I could tag people on this forum haha)
That they feel the need to write 4 paragraphs to defend against this elephant in the room says a lot. The question we are all still asking is how much better (if at all) StrongMinds really is than cash for wellbeing.
My first question is why don’t they reference the 2020 Haushofer study, the only RCT comparing psychotherapy to cash and showing cash is better? https://www.nber.org/papers/w28106
Second, their equipoise argument is very poor. The control arm should have been BRAC ELA club + cash. Then you keep 3 arms and avoid their straw man 4 arm problem. You would lose nothing in equipoise giving cash to the control arm—I don’t understand the equipoise argument perhaps I’m missing something?
Then third there’s this...
“Should the trial show that IPT-G+ is significantly more effective than IPT-G alone in reducing depression in the medium-run, our interpretation will be that there is a complementarity between the two interventions, and not that cash is effective on its own for sustained improvements in psychological wellbeing.”
This is the most telling paragraph. It’s like, we designed our study so that even if we see that cash gives a big boost, we aren’t going to consider the alternative that we don’t like. It seems to me like they are defending poor design post-hoc, rather than that they made good decision made in advance.
The more I see this, the more I suspect that leaving the cash arm out was either a big mistake or an intentional move by the NGOs. What we have now is a million dollar RCT, which doesn’t answer conclusively the most important question we are all asking. This leaves organisations like your HLI having to use substandard data to assess psychotherapy vs. cash because there is no direct gold standard comparison.
It’s pretty sad that a million dollars will be spent on a study that at best fails to address the elephant in the room (while spending 4 paragraphs explaining why they are not). Other than that the design and reasoning in this study seems fantastic.