By Tom Sittler
Read and comment on the Google Document version of this post here.
This is part of a series of posts about our progress in the first five days of the Oxford Prioritisation Project.
Lovisa Tengberg, “Are Mental Health interventions a possible target for the Oxford Prioritisation Project?”
Lovisa wrote a research memorandum on mental health interventions. The below is a summary of its main conclusions:
According to a report by the Center for Global Development (CGD) in 2015, up to 10% of people (~700 million) worldwide are affected by mental health problems such as depression, substance abuse, dementia or schizophrenia, and over a billion are likely to experience one in their lifetime, including 80% from low- and middle-income countries (LMIC). It is among the top five leading causes of non-communicable diseases, and represents 7.4% of the world’s total global burden of disease, accounting for 22% of all days lived with disability (as measured in DALYs). According to the GCD report, the DALYs due to mental illness grew by 38% in the twenty years between 1990 and 2010, and is expected to continue on this trajectory as populations age and demographics shift (since mental disorders are most commonly diagnosed in the adult years).
Mental health however is largely neglected at a national level both in developed and developing countries, where in the latter – according to the Mental Health Atlas 2014 -public expenditure levels for mental illnesses are very low at US$2 per capita (compared to US$50 per capita in high-income countries). According to the GCD report, “one third of LMIC do not have a designated budget for mental health…and among those that do, the average expenditure on mental health in low-income countries 0.5% of the total health budget”, of which a large proportion is spent on inpatient care. According to the GCD report however the international donor community also neglects mental health, where only 0.7% of the total health budget is directed at promoting mental health or preventing or treating mental disorders.
Nevertheless, mental health has received global public health attention in the last two years, particularly since its inclusion in the Sustainable Development Goals. Further, a number of new national mental health policies have been approved in the last ten years from LMIC, with particularly high impact potential in India, China, Ethiopia, and South Africa.
Out of eight listed NGOs (Centre of Global Mental Health), only BasicNeeds works on a larger scale across borders in both Africa and Asia. GWWC profiled BasicNeeds and concluded that they “were not able to do a full-cost accounting analysis, because BasicNeeds were unable to provide us with the details of their partners’ costs, making it difficult to assess the cost-effectiveness of the programmes as a whole”.
According to the CGD report, “a significant and ever-growing body of evidence shows that effective interventions for mental disorders can be delivered at low-cost in LMIC”. The cost-effectiveness of the different interventions in terms of $ per DALY varies significantly, and the estimates further are “highly uncertain as there is a lack of high quality evidence for mental health interventions in LMIC.”
The perhaps largest obstacle to effective treatment is the belief in LMIC that mental health problems don’t exist, a fear of contagion, and stigma, leaving it untreated and leading to human rights abuses such as incarceration, forced restraint, and sexual abuse.
Of the psychological interventions, there are now hundreds of for-profit intervention ‘apps’ available mostly in the developed world, and a few non-profit apps focused on the developing world, mostly limited in scope to one country. Mental health app developers however rarely conduct or publish trial-based experiment validation of their apps, and according to a review on mental health smartphone apps, a previous systematic report revealed a complete lack of trial-based evidence for many of the apps available.
Given the limited data available and uncertainty about the effectiveness of the programs, donations to BasicNeed or any app intervention is not recommended.
Nevertheless, given the large prevalence of mental illnesses, the trajectory of mental illnesses increasing, and the potential large-scale impact, there is significant reason for funding research that potentially could identify cost-effective interventions and policy recommendations. In regards to OxPrio Project’s priorities, if we are able to find promising research projects that accept donations (with emphasis on “if”), either with focus on philanthropic interventions or on policy changes, there is potential of high impact within the space. The difficulty lies in where to channel such funding as - to my knowledge - there are few, if any, organizations pushing effective interventions. Thus unless such channels are identified, I propose we invest our £10,000 elsewhere.
After a discussion in the second full-team meeting, it emerged that it may be difficult to find good object-level funding opportunities in this area (e.g. it’s difficult to evaluate the cost-effectiveness of BasicNeeds). However, given the importance and uncrowdedness of this focus area, the value of information from getting more empirical data on interventions seems high. On the other hand, it may be difficult to fund research projects in a targeted way with just £10,000. Lovisa decided to spend some more time researching what the Oxford Prioritisation Project’s concrete options for funding work on mental health would be.
(See also: See a longer version of Lovisa's memorandum here.)