Lovisa Tengberg: "Mental Health: an update"

By Lovisa Tengberg, Fellow.

This is a follow-up to a previous post. Read and comment on the Google Document version of this post here.

Summary

As discussed in previous meetings and on Slack, I have looked into 1) General numbers on cost-effectiveness within MH; 2) Whether there are research institutions that could be potential recipients for the OxPrio Project; 3) More detailed info on BasicNeeds; 4) Detailed info on StrongMinds. On the first note, I found in the DCP3 report that there was little evidence on the cost-effectiveness of various interventions. The numbers that do exist vary significhantly between and within disorders driven by cost of labor and contacts with the health care system, making a cost-effectiveness analysis difficult to create. On the second note, I found no research institutions that would be relevant for our purposes. Third, it could be worth doing a more detailed analysis of BasicNeeds, but given GWWC’s review I am skeptical of their effectiveness. Fourth, StrongMinds is still fairly small and operate only in Uganda, but it looks like it has a possibly scalable and cost-effective methodology and ambitious goals which are worth looking into further. The numbers I have listed below for both BasicNeeds and StrongMinds are the only available ones (to my knowledge), and to my understanding we need more in order to create a working model (? - please correct me if I’m wrong).

 

General on MH

As already mentioned in a previous report on 2017-01-26, MH and substance disorders represents 7% of the DALY burden worldwide and 6.5% in developing countries. Depression, anxiety and drug disorders account for approx. 50% of this burden. Disorders are treated through a wide range of drug-based, psychological and social interventions.

According to the DCP3 report, in terms of self-care and informal health care interventions,

there is very limited published evidence on the cost-effectiveness of population-based or community-level intervention strategies in LMIC (but also in HIC, limiting the usefulness for studies for LMIC), reflecting the “highly heterogeneous nature of the practices undertaken, as well as a lack of established efficacy for them”.

In terms of primary health care, there is still very limited published evidence, but it is clear that a combination of pharmacological and psychosocial treatment (with no specification of which psychosocial treatment) leads to the best overall balance (including cost-effectiveness) for severe mental disorders. The cost-effectiveness of mental health varies substantially between interventions, with the most cost-effective being brief interventions such as for substance abuse and epilepsy, with the least cost-effective by far being drug-based, psychological and social intervention for schizophrenia. The most cost-effective of the strategies range from US $3,300 - US $14,000 per healthy life year gained for schizophrenia and bipolar disorder, from US $800 – US $3,500 on an episodic basis for depression, <US $1,000 for alcohol abuse interventions and from US $600 – US $2,500 for epilepsy drug treatment. Graph overview can be found on GWWC’s website (could not copy it in here for some reason). Differences in costs are largely driven by the cost of labor and contacts with the health care system. (See annex 12C of the DCP3 report for detailed research project sources, and details of cost-effectiveness in annex 12D.)

 

On another note, Michael Plant (PhD student at Oxford) argues that the QALYs/DALYs likely underrate the badness of mental health conditions on happiness for two reasons: 1) They are measures of health, not happiness, and 2) the weighting is created by asking how bad they expect various conditions to be rather than assessing asking people to report their subjective well-being. Plant states “As mental health conditions are hard to imagine and hard to adapt to…they might be 10-18 times worse than we imagine them to be.”  “If this is the case then funding MH charities is the most cost-effective way of increasing happiness.”

 

Research

I looked into various research institutions as potential recipients, and there are numerous focused solely on mental health, particularly in developing countries. Larger multi-national organizations or programs are the PRIME project, the EMERALD consortium, AFFIRM, are the AMARI grant, funded by the Department for International Development (UK), the European Commission, the National Institute of Mental Health (USA), and the Department for International Development, respectively, and as far as I can tell they don’t accept donations of our kind (I have emailed and called to ask each of them but no reply). I have also looked at ‘smaller’ organizations such as Africa Mental Health Foundation (AMHF) active in Kenya, where it is unclear if donations are received, but in either case where (and if) evidence of cost-effectiveness exists, there will be none of ongoing projects, making it difficult for us to prioritize amongst organizations. If anyone has another view on this, please do let me know.

The only possible recipient I found was the Global Mental Health Program at Columbia University, where they openly accept donations on their website. In doing so we contribute to education & training of students, clinicians and researchers, research, and advocacy of the arts (engaging with the Arts as a lens to understand mental illness). However, given their various projects it will be difficult to target research and assess the cost-effectiveness of each program. My conclusion is that I don’t think a research institution is a relevant target for us.

 

As discussed, I also looked into BasicNeeds and StrongMinds, the two relevant charities in the field: 

BasicNeeds

Key facts:

·      Since 2000

·      Total affected participants: 37,000 (out of which ~42% live with epilepsy)

·      Total people who have gone through programme: ca 680,000

·      Total staff: 110 (+ 70 partner staff + ca. 3000 health personnel & community workers)

·      Active in 12 countries

·      On average, the cost of implementing the BasicNeeds Model per participant was US $9.67 per month

·      (Unreliable?) study in Kenya showed US $727 / DALY averted (see ‘Cost-effectiveness and robustness of evidence’ below)

·      After joining programme: 80% accessed treatment (baseline 58%), 80% were able to work (baseline 52%), 78% people reported reduction in symptoms (baseline 0%)

·      Partners with Ministries of Health and the WHO

 

Description

BasicNeeds is an iNGO working in partnership with locals across LMIC Africa and Asia, implementing an innovative model for recovery and sustained good mental health in resource-poor settings. They work with individuals and communities, local and national governments, and international organizations, including the WHO. BasicNeeds s approach to treatment involves providing medication and psychosocial support in partnership with local governments and Ministries of help. They build the capacity of existing health professionals and services and thus are low cost and sustainable. They also help by encouraging members to self-help groups and create livelihood opportunities to support individuals to gain or regain their ability to work, earn and contribute to family and community life. Lastly, they reduce stigma by raising awareness.

 

Cost-effectiveness and robustness of evidence

BasicNeeds uses a task-shifting model where treatment and coordination is managed by laymen. Thus GWWC are reasonably confident it does not divert the number of MH professionals from other patients, resulting in an increase in the number of people treated. BasicNeeds raises awareness and advocate for change in local and national mental health policy. According to GWWC there has been significant reform in MH policies in five of the countries where BasicNeeds operates, although they are not confident what role BasicNeeds has played in such change.

BasicNeeds’ interventions tend to fall in the less favorable range of interventions considered in the DCP3. Further, GWWC reports that “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”. BasicNeeds nevertheless conducts routine evaluations of their programs. According to GWWC, one study on the cost-effectiveness in Kenya reported $727 per DALY averted, although there was no control group, no calculations given and further the study was implemented by BasicNeeds employees.

GWWC were not able to do a full-cost accounting analysis, as BasicNeeds were unable to provide them with details of their partners’ costs, and I was unable to find any additional facts on their website or annual report.

 

Track record and quality of implementation

See ‘Key Facts’ above.

After interviews with BasicNeeds employees and experts in the field, GWWC believes BasicNeeds to be a high quality and reasonably transparent organization. It was recognized as the top organization working in MG by WISH in 2013.

 

Room for funding

GWWC are confident BasicNeeds can absorb additional funds up to $250,000 in 2017. Additional funds will be used to maintain operational capacity in the UK and fund additional partners to expand the programme to new locations.

 

StrongMinds

Key facts:

·      Pilot program in 2014/2015

·      Treated for depression: 7,136

·      Goal: To treat 2 million African women with depression by 2025

·      Plan on expanding to Kenya in 2018

·      Estimated US $34 / DALY averted by MHIN - Mental Health Innovation Network (the World Bank describes interventions below US $100 / DALY averted in developing countries as highly cost-effective)

·      82% depression-free at conclusion of treatment

·      80% depression-free 6 months post treatment

·      67% decrease in unemployment

·      ~75% of groups continue to meet after formal sessions conclude

·      Focus on women as they have a higher chance of developing during or after childbirth (about 10% of pregnant women and 13% of those who have given birth recently in LMICs suffer from anxiety and depression.)

 

Description

StrongMinds is a charity that treat women in Uganda with depression (only) through a ‘unique’ depression intervention, based on Group Interpersonal Psychotherapy (IPT-G), a low-cost, scalable and cost-efficient community based methodology. 

StrongMinds mental health facilitators are local professionals who are trained and certified in StrongMinds model. Groups are led by such facilitator over a period of 12 weeks to help members identify the root causes and triggers of depression, and formulate strategies to overcome such triggers to help patients both immediate and long-term. They further help women start their own Peer Therapy Groups after treatment. Before participating, women are evaluated via a quantitative diagnostic tool recommended by the WHO for use in developing areas in order to determine the presence of depression for prospective participants, allowing a more rigorous assessment of the illness.

The New York Times called the work of StrongMinds “A Depression Fighting Strategy That Could Go Viral”. According to Chelsea Tabart of GiveWell, they have randomized evidence of effectiveness, are transparent, and is in her assessment potentially highly cost-effective, and is supported by monitoring published online.

 

Cost-effectiveness and robustness of evidence

StrongMinds conducted extensive research to identify the most appropriate treatment intervention, and the methodology was first tested in Uganda by John Hopkins University in a RCTin 2002, and was conducted again by JHU in 2012 with equally successful results (see ‘key facts’ above). They piloted in 2014, aiming to experiment and modify the treatment as the organization gains ground expertise as they continue to measure the overall well-being of the women and their families.

StrongMinds are developing a scalable model that can resolve depression at an estimated cost of US $34 / DALY averted, but significant increases in overseas and development assistance financing for MH programs are needed for StrongMinds to reach their goal of treating 2 million women by 2025.

 

Someone on the Effective Altruism blog posted a cost-effectiveness analysis of StrongMinds. Although not complete – if accurate – it provides us with some valuable key numbers. Happy to try to contact writer if we find it relevant – perhaps (and hopefully) he has advanced it since his last post.

 

Track record and quality of implementation

The evaluations of StrongMinds shows that patients who complete treatment have greater ability to grow livelihoods, save income, adhere to health treatments and care for their children. See key facts above.

Room for funding

No info available to my knowledge.